(a) Name

(b) Address

(c) Education

(d) Phone no

(I) Mobile

(II) Landline

(e) Email address

(f) Website

(g) Date of birth

(h) Gender

(i) Age

(j) Your Hobbies

(I)

(II)

(III)

(IV)

(a) Disease

(VI) Skin disease

(VII) Pneumonia

(VIII) Harpies

(IX) Urine stone

(X) Skin Rashes

(V) Typhoid

(III) Chicken poxe

(IV) Malaria

(II) Small pox

(I) Jaundice

(b) Operation- If you gone through any operation kindly mention it.

(I) Is it from maternal side :

(II) Is it from paternal side :

(A) Time to wake up :

(B) Are you habitual for :

(C) Exercise :

If yes then please give detail :

(D) Bath :

(E) Working hours:

(F) Work culture

(G) Do you have to travel daily:

(H) If yes then how much kilometers :

(I) Lunch time :

(J) Dinner time :

(A) Stools :

(I) Do you have regular motion :

(II) How many times do you have motions in a day?

(III) Do you have good sensation of defecation:

(IV) Nature of your stool:

(V) Gas trouble:

(VI) Odor:

(VII) Have you ever stop your emotion for defecation or you have a tendency to do so:

(VIII) Do you have habit of reading while toileting:

(IX) any other complains about stool :

(B) Urination :

(I) for how many times you have urinations :

(a) In a day :

(b) In a night :

(II) Odor- Can you smell any odor for your urine :

(a):

(b) :

(III) Color :

(IV) Burning sensation :

(V) Have you ever stop your emotion for urination or you have a tendency to do so :

(VI) Any other complication :

(C) Sweating :

(I) I have sweating for:

(II) I have sweating as per:

(III) Odor:

(IV) Do you have more sweating on palms of hand & feet:

(D) Menstruation :

(I) At which age did you have menarche (First menstruation):

(II) Your menstruation is:

(III) Menstruation occurs after ------------ to ------------- Days:

(IV) Total number of days for menstruation:

(VI) Clots in menstruation:

(V) Color:

(b) If yes then- clots are in large amount/minimum amount:

(VII) Do you feel any change in your nature before menstruation :

If yes then specify :

(VIII) Do you feel any change in your nature during menstruation :

If yes then specify :

(VIII) Do you feel any change in your nature after menstruation :

If yes then specify :

(X)   Did you ever notice some white discharge :

(XI)  How is your menstrual bleeding :

(E)   Sex Life :

(I)   Are you happy with your sex life :

(II)  For how many times you have sex :

(III) Masturbation :

(IV) Do you feel burning sensation during sex :

(V) Have you ever stop your emotion for sex or you have a tendency to do so :

(VI) Only for females :

(a) Any use of contraceptives :

(b) Any abortion :

(c) Any other complication :

Please specify if any:

(d)Total numbers of child you have :

F) Sleep :

(a) At night :

hours of sleep

(b) Do you have a good sound sleep/you wake up in night & again try to sleep

(c) Do you have a habit of sleeping

(I) In a afternoon :

(II) After lunch :

(d) Do you have to stay awake late in night :

(e) Do you have any unusual habit during sleep like walking/talking/toileting in bed :

G) Your nature is :

(H) Are you habitual for :

(I) Do you ever feel fatigue in your daily schedule-at morning/at afternoon/at evening/at night :

(J) Do you forgot easily :