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Personal Details
First Name
Last Name
Address
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Weight
Height
Date of Birth
Reason for Consultation
Expectation
Alcohol (units per week)
Tobacco (per day)
Caffeine (per day)
Family History
Stroke
Cancer
Heart Disease
Neuropsychiatric Disease
Obesity
Gout
Allergies
Blood Disease
Joint Disease
BP Problems
Arthritis
TB
Personal History
Measles
Vaccinations
Bronchitis
Scarlet Fever
Tonsilitis
Asthma
Chicken Pox
Glandular Fever
Allergies
German Measles
Colds
Eczema
Flu
Whooping Cough
Operations
Accidents
In the last two years have you received treatment from a medical or alternative practitioner. If yes please give details:
If you are taking any medication/natural remedies please give details:
General Health
Chronic tiredness, general lassitude
Tiredness in the morning
Progressive tiredness owing to lack of resistance
Tiredness in the morning, reappearing in the afternoon
Irregular tiredness, exhaustion
Tires after effort
Refreshed by effort, tireless in the evening
Has always been like this
Memory and Concentration
Selective, recent memory disturbances
Reduced in relation to tiredness
Reduced with age
Very poor
Nature
Very energetic
Moderately energetic
Less energy than before
Lacking in energy
Slight pessimism, anxiety, emotional liability
Pessimism with depresssion
Mental state neither good nor bad
Mental state fluctuating
Optimism
Character
Calm, thoughtful, self-controlled
Nervous, choleric, easily 'carried away', impatient
Nervous, anxious, emotional
Apathetic, listless, general lack of interest
Alternating moods
Sleep
Need for lot of sleep
Duration of sleep reduced because of intense life
Poor sleep with anxiety, waking during the night
Difficulty getting to sleep
Poor sleep with nightmares
Drowsiness
Infections
Susceptible to infections
Very susceptible to infections
Adenitis
Staphyloccal infection
TB
Others
Head
Headaches, migraines
Auditory disturbances
Dizziness, drop in BP, feel faint
Dizziness, low BP, feeling faint
Respiratory System
ENT infections
Hayfever
Hayfever with infections complications
Asthma
Bronchitic Asthma
Bronchitis
Sinusitis
Pleurisy
Breathlessness
Urinary Tract
Frequent or infrequent urination
Cystitis
Bed-wetting
Incontinence
Digestive System
Irregular appetite
Lack of appetite
Food intolerance
Nausea
Constipation
Diarrhoea
Alternating Constipation/Diarrhoea
Slow Digestion
Colic
Wind/Bloating/Flatulence/Burping
Peritonitis
Gastritis Duodenitis
Ulcer
Chronic Enterocolitis
Colitis/Rectocolitis/Sigmoiditis
Stools
- Frequency
- Consistency
- Colour
- Odour
Cardiovascular System
Hypertension
Hypotension
Palpitations
Tachycardia
Pericarditis
Angina pectoris oppression, radiation, anguish
Varicose veins
Haemorrhoids
Oedema of the legs and/or ankles
Nocturnal cramps
Tingling
Cold or numb extremities
Blue/purple fingers or extremities (Acrocyanosis)
Excessive urination at night
Osteoarticular System
Fleeting pains
Chronic, progressive pain, deformities
Joint disease; pain at start of day, every day
Arthritis; pain all day during 'flare up'
Gout
Osteomyelitis
Skin, Hair and Nails
Non-infected eczema
Infected eczema
Pruritis (itching), Urticaria (hives)
Quincke's Oedema
Brittle hair and nails
Hair loss
Endocrine System - Pancreas
Undigested stools
Putrid diarrhoea
Weight loss
Weakness
Exhaustion
Ravenous Appetite
Adrenal Glands
Loss of strength and physical weakness
Hypotension
Depression
Vomiting
Diarrhoea
Drowsiness
Hyperthyroidism
Hypertension
Variation in weight
Hot flushes
Nervousness
Palpitations
Diarrhoea
Hypothyroidism
Hypotension
Slow-wittedness
Apathy
'Chilly' feeling
Constipation
Parathyroid Disturbances
Hyperreflexia (muscle twitching)
Hyperexcitability (excessive mental and physical activity)
Cardia Arrhythmias, Tachycardia
Muscular contractures
Spasms
Genitals
Frigidity, Impotence
Frequent, heavy, painful menstruation
Infrequent, light menstruation
Irregular menstruation
Menstruation absent
Menopausal disturbances
Sterility
Pregnancies
Miscarriages
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