Please fill in this questionnaire in as great detail as possible. Things that you might feel are "medically not relevant" can give important information, such as your habits, patterns of behaviors, moods etc. So please report such things fully. Include any strange feelings and sensations that you think might be important, even if they are not specifically asked for in the questionnaire. Such information might give helpful information about your individual reaction to the illness, and thus help us prescribe the best medication for your problem. Of particular importance are changes that you have noticed recently, in appetite, in desire or aversion for particular foods, in behaviors, sleep patterns, bowel habits, dreams etc., so please report any such details that you have noticed.

Name :  
Age :
Email :

Please write a brief account of your present problems and information about how long you have had them (in chronological order). (eg :"Difficulty in breathing started in --- after being out in the cold for--- days.")



Going all the way back to paternal and maternal grandparents. (Allergies, skin problems, asthma, Alzheimer's, migraines, any other neurological disorders, heart problems, cancers, mental disorders, etc. For example, " Elder sister has/had eczema, paternal aunt died because of complications of heart disorders, maternal grandma had Alzheimer's," etc.



(As far as you can remember) whether your delivery was normal or caesarian, whether there is a history of neonatal jaundice, measles, mumps, typhoid etc. Any effects of vaccinations like fevers, loose bowels, frequency of colds, running nose, coughs.


And also:

Milestones of life (as far as you can recollect): teething, trying to sit up, walking, talking, etc. (on time, delayed, early).


History of broken bones, accidents, head injuries, dog/insect bites etc.



(a) How is your appetite? :
(b) Is there a tendency to indulge in particular kinds of foods (eg: sweets, sour foods, salty foods, etc.) :
(c) Are you allergic or sensitive to any foods? :
(d) What kind of weather are you most comfortable in?
(Summers, humid weather, winter)
(e) Are you particularly uncomfortable in any weather or climate? :
(f) Do you sweat at all?
If you do, where do you sweat noticeably? (Scalp, upper lip, under arms, back, chest, etc.)Under what circumstances?
(While eating, under tension, when you physically exert yourself etc.)
In general do you like being out in the open air or do you feel more comfortable in closed rooms? :
Do you dream at all? If you do, do you remember them? What is the content?
(eg: daily events, falling into space, running after a train, etc.)
How is the quality of your sleep most of the time? (Rested and refreshed, feel tired most mornings etc.) :
How is your bowel habit?
(Regular, constipated, diarrhea etc.) Is it modified by anxiety? By diet (eg. spicy food causes diarrhea)?
How is your liquid intake?
(Feel thirsty all the time, fairly normal etc.)

How would you describe yourself? (Amiable, a loner, quite social, a tendency to be very picky about things like cleanliness and keeping appointments etc.)


How do you react to stress and tension? (Tend to be verbally expressive, tend to keep things to yourself and brood about them, etc.)


Additional Information(if any)


Age at onset of periods? :
Periods? (Regular/Irregular) :
Physical symptoms preceding the onset of periods (eg: heaviness/pain in the breasts, changes in moods, changes in appetite, changes in bowel habit, backache, pain in the legs, headaches, dreams etc.)? :
Duration and interval between periods (eg: bleeding last for 3-5 days and the interval between periods is 27 days)? :
Are you using any contraceptive pills? :
Any discharge before/during/after periods? :
Number of children and whether the deliveries were normal? Any post-delivery problems? Were the children breastfed or not? Any problems during the breastfeeding phase? Any abortions? Any complications after abortions? :
Age of onset of menopause? :
Did the periods cease gradually or abruptly? :
Have you had any operations done in the pelvic area?  

Instructions to Patients Following instructions to be followed

  • Mouth should be clean while taking the medication.
  • Maintain 15 minutes gap before and after the medication.
  • Keep the pills preferably under the tongue and the let the pills melt.
  • Maintain longer gap on taking mint, coffee, onion, garlic or anything that leaves a lingering taste in the mouth.
  • The medicines can be had even on an empty stomach.
  • Avoid touching the medicines with the hand.
  • The day the packet is taken avoid taking the pills from the bottle,unless advised.
  • Medicines in liquid form can be had immediately after food, no gap is required.
  • The medicines may seem dry after a few is very normal as the spirit in it evaporates each time you open the bottle but the medicinal effect will be very much intact.
  • Maintain 1-hour gap between any other system of medication like allopathic, ayurveda etc.
  • If you are taking medicines for B.P., DIABETES, THYROID or CARDIAC PROBLEMS continue the medication unless the doctor advises you otherwise.
  • Always call up the clinic before you visit the doctor to check if the doctor is available. Fix up an appointment so that you don't have to wait long to see the doctor.
  • Preparing medicines at the dispensary takes time. Please co-operate with them.
  • We are making our best efforts to keep up the appointments schedule on time, if there is any delays due to unavoidable circumstances please co-operate with us.
  • For any further clarification please contact the reception or contact the doctor.
  • Patient are free to call up the doctor on his emergency no. any time of the day or night in case of an emergency.
  • At his mobile 9440190488