Fill in the detailed Pre-treatment analysis form


Your General Nature : (Anger, extrovert or introvert, emotional, decision making quality, childhood nature, how you take criticism etc.)

Details about your present Disease/ailments in order of appearance with duration

If you have already seen a doctor, what diagnosis did they give you?

What investigations, tests have you undergone? Please mention the reports and brief treatment history.

Is there anything else that might be helpful or relevant to your problem? including allergies, illnesses that run in the family and a little bit about your lifestyle.

Past History :(Diseases or symptoms you have suffered in past, with treatment history)

Physical Generals

Which weather you prefer most :

Appetite :

Thirst :

Liking for specific taste/food :

Sensitivity : (To noise/ light/ sunlight/ high neck, ties/ narrow places/ closed rooms/ traveling in vehicles/ by air/ perfumes/ dust/ others)


Gynae and Obs history :

Menstrual history :

Age of menarche/ menopause :

History of abortions or miscarriage :

Family history

Name the diseases which your father/ mother/ siblings might have suffered

Anything else you would like to share with the doctor?