Doctor-ph-form - The Curing Tree

Program

Male Female

Name

Date

Age

Father/Husband Name:

I. Any Family History of

High Blood Pressure :

Father

Mother

Siblings

Others

Heart Diseases :

Father

Mother

Siblings

Others

Diabetes :

Father

Mother

Siblings

Others

Thyroid :

Father

Mother

Siblings

Others

Cancer :

Father

Mother

Siblings

Others

Lung Ailments :

Father

Mother

Siblings

Others

Anaemia :

Father

Mother

Siblings

Others

Epilepsy :

Father

Mother

Siblings

Others

Neurological Issues :

Father

Mother

Siblings

Others

Allergies :

Father

Mother

Siblings

Others

Others:

II. Your Past Medical History

Diabetes/DM BP/HTN Heart/Cardiac Cancer TB Hormonal Issues Lung Ailments Epilespy/Fits Liver Ailments Surgeries Injuries Typhoid Jaundice Gastric problems Piles, Fistula, Fissures Skin issues Migraine Allergies Appendicitis Gyaec Problems Kidney or Bladder Issue Viral Infections Bacterial Infections Parasite Infections COPD CAD (Coronary Artery diseases) CVA (Cerebro Vascular diseases)

If undergone any medical surgeries:

III. Your Present Medical History

Neurological

Headache/Migraine Depression Dizziness/Tremors/Numbness Seizures/Epilepsy Stroke Paralysis Blackouts Sleep Related Issues

Others:

Gastrointestinal

Hemorrhoids, Fistula, Fissures Constipation Indigestion Diarrhoea Flatulence Burpings Bleeding H.pylori infection Hepatitis Jaundice Fatty Liver Ulcerative colitis Acidity (Burning sensation/Tightness in chest) Gas/Bloating GERD Gall bladder stones

Others:

ENT

Hearing Problems Vision Change Vertigo Thyroid Tonsillitis Enlarged Adenoids Tinnitus Sinusitis Bleeding Gums

Others:

Genito-Urinary

Bleeding Flank pain Burning sensation Frequency Urgency Incontinence UTI Low Creatinine levels High Creatinine levels Kidney Calculi Sexual Problem

Others:

Cardiovascular

Swelling in legs Pain in legs Chest pain High lipid profile (Cholesterol/Triglycerides) Dyspnoea or difficulty in breathing Sweating & breathlessness climbing stairs

Others:

Muscle-Skeletal

Joint Pain's Sciatica Gout Back Pain or neck pain or spondylitis Fractures Cramps Numbness Stiffness Swelling Firbromyalgia Muscular Dystrophy

Others:

Hematopoietic

Bruising Circulatory Issues Weakness Anemia Giddiness

Others:

Skin

Itching Bleeding Ulcers Eczema Rash Psoriasis Patches or Discoloration Dermatitis Urticaria

Others:

General

Sudden Weightloss Sudden Weightgain Weakness Chills/Fever Sweating

Others:

Vitamin Deficiencies

A D3 C B12 Calcium

Any other deficiency:

Autoimmune Diseases

Rheumatoid Arthritis Thyroid Celiac Disease IBS Vasculitis Lupus Neuropathy Multiple Sclerosis Diabetes Type 1

Others:

Menstrual History

Cycle

Regular:

Late:

Early:

Amenorrhea Menopause

Bleeding - Days (No.):

Delivery

Term Pre-term Post Date

Delivery Type

Normal LSCS Assisted vacuum forceps

Children - no. of children:

If Abortion - Cause:

IV. Allergies

Drugs:

Food:

Others:

V. Lifestyle Habits

Cigarettes / Tobacco

Social smokers Anxious smokers Addicted smokers Others

Alcohol

Weekly Social drinker Alcoholic Others

Tea / Coffee

Low Moderate Addicted Others

Sleep Pattern

Sleeps late almost every night Sleeps late occasionally Regular 8 hours sleep Regular but less than 8 hours sleep Insomnia

Exercise

Intense exercise everyday Moderate exercise everyday Exercises Occasionally Will not exercise

Type of exercise:

Duration:

VI. Are You Under Medication and For

Allopathy:

Homeopathy:

Ayurveda:

Reports

Advice