Full Name
*
Prefix
First Name
Middle Name
Last Name
Birth Date
*
Please select a day
1
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Day
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a year
2025
2024
2023
2022
2021
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1923
1922
1921
1920
Year
I Am
*
Male
Female
SECTION 1
Basic Information
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Number
*
E-mail
*
example@example.com
Occupation
*
Service - Table Work
Service - Touring Job
Profession
Housewife
Student
Main Case Paper
Your Weight in KG
*
Main Complaints
*
Factors - Increasing / Decreasing Symptoms
*
Previous Illness History
*
Any Surgical History ?
*
Yes
No
If Yes...Give Details
Family History
*
Routine
Wake up
*
Before Sunrise
After Sunrise
Excercise ?
*
Daily
Sometimes
Never
Type of Job
*
Sitting Job
Hectic Job
Stressfull
In Air Conditioned
In Hot Surrounding
Shift Duty
Night Duty
Continuously in Front of PC / Laptop
Travelling Job
House Work
Your Appetite ?
*
Good Appetite
No feeling of Appetite
Some Times Good Some times No Feeling of Appetite
Your Timing of Having Meal..
*
Reglar
Irregular
Only After feeling of Appetite
Scheduled as per Timing
Other
Do you have Breakfast ?
*
Yes
No
Sometimes
Breakfast Timing
*
Morning
Evening
Both Times
None
Do You Feel Hungry @ Breakfast
*
Yes
No
Do not Take Breakfast
Timing of Lunch
*
10.00 AM - 11.00 AM
11.00 AM - 12.00 PM
12.00 PM - 02.00 PM
Before 10.00 AM
After 02.00 PM
Timing of Dinner
*
Before Sunset
07.00 PM - 09.00 PM
09.00 PM To 10.00 PM
10.00 PM Onwards
Very Irregular
Maximum Consumption of
*
Sweet Food
Sour Food
Salty Food
Bitter Food
Pungent Food
Stringent Food
Bowel Habbits
*
Yes
No
Sometimes
Do you visit Toilet Daily
Do you have experience bowel discomfort or pain
Do you need Tea / Coffee / other things for Sensation
Nature of Stool ( Tick which is Applicable )
*
Solid
Semisolid
Watery
Sticky
Yellowish
Dark Yellowish
Brownish
Geenish
With Blood
Urine Frequency
*
2-3 times in 24 Hrs.
4-6 times in 24 Hrs.
More than 6 times in 24 Hrs.
More in Day Time & Not During Night
Sometimes during Night Also
Always during Night Also
Other
Sweating / Perspiration
*
Continuous sweating Round the Year
Only in Summer
More Than Others
Just After Physical Work
Profuse with Smell
Stains Cloths
More on Palms
About Your Sleep
*
Sound sleep in Night
Breaking Sleep
Other
Do you Have Afternoon Sleep After Lunch ?
*
Yes
No
Sometimes
Stress Level
*
1
2
3
4
5
6
7
8
9
10
Very Less
Too Much Stress
1 is Very Less, 10 is Too Much Stress
Finalise your Submission
Did you take Medicication or other treatment for this / Other Illness ?
*
Yes
No
If yes, Give Details with medicines or other treatment
SECTION 2
Do you drink any boxed Juices from the shops?
*
Yes
No
Do you consume any candies? (Sweets)
*
Yes
No
Other
Do you eat chocolate?
*
Yes
No
Do you eat meat,and that includes fish?
*
Yes
No
Do you eat ice cream?
*
Yes
No
Do you eat pizza?
*
Yes
No
Do you eat any fruit? If so,how many per day
*
Yes
No
If yes,please provide details
Do you eat raw foods as a full meal at all?I.e, lettuce,broccoli,fruits,etc
Yes
No
Do you use dairy products,e.g. cow's milk,cheese?
Yes
No
Do you eat eggs?
Yes
No
What do you eat for breakfast?
What do you eat for lunch?
What do you eat for supper?
How many teaspoons of sugar or honey, do you put in your cup of coffee/tea?
What do you use as spreads on your bread, e.g. butter, jam, peanut butter, honey etc? (Please explain the type of spread you use, e.g. Ranch house peanut butter)
Do you drink soy milk?
Yes
No
Do you drink rice milk?
Yes
No
Do you drink almond milk?
Yes
No
Do you eat French fries?
Yes
No
Do you eat any burgers?
Yes
No
What kind of cooking oil do you use for cooking?
*
Do you fry your foods?
Yes
No
Do you use a microwave?
Yes
No
Do you read labels when you buy bottled or packed foods?
Yes
No
Does your pre-packed soups have MSG in it (Monosodium Glutamate) or you don’t know?
Yes
No
Do you know what Aspartame is?
Yes
No
What kind of toothpaste do you use?
What kind of bath soap do you use?
Do you have any stress at all? Do you know what causes it?
Are you happy when you go for work or when you come home,why?
If you have stopped eating anything for some time, what is it, reason, and when was that? E.g. rice, tea, fish etc.
Do you have any dental Fillings? How many? For how long?
How many times have you visited the Doctor with your current problem?
(For males)Are you pre-occupied with a possibility of having prostate cancer?
For Ladies:
Are you pregnant?
Yes
No
Are you on Menopause?
Yes
No
Are you Breast feeding?
Yes
No
Are you on birth control pills – which one?
How many hours do you work per day?
How many children do you have?
How high are your shoes? High or flat shoes.
SECTION 3:Additional information
Do you have any of the following?
Heart rhythm disturbances (Irregular heart beat)
Yes
No
Constipation and /or sluggish colon.
Yes
No
Chronic fatigue.
Yes
No
Muscles tear or injure easily.
Yes
No
Muscle cramps (or cramps in the bottom of the feet)
Yes
No
Depression.
Yes
No
Muscle weakness.
Yes
No
Inability to control bladder.
Yes
No
Night sweats.
Yes
No
Excessive body odor.
Yes
No
Muscle twitching.
Yes
No
Lower or mid-back pain.
Yes
No
Muscle tension or tight muscles.
Yes
No
Dizziness.
Yes
No
Enlarged facial pores.
Yes
No
Uncontrollable sweating of the hands, feet, and /or armpits.
Yes
No
(Women) Painful menstrual cramps.
Yes
No
(Women)(PMS)
Yes
No
Restless leg syndrome ( i.e. constant jerking or motion of the legs at night)
Yes
No
Chronic knee and /or hip pain.
Yes
No
Cold hands and /or feet.
Yes
No
Lack of appetite.
Yes
No
Sudden episodes of loss of brain function (Mesmerized)
Yes
No
Nausea.
Yes
No
Rapid heartbeat (above 80 beats per minute)
Yes
No
Carpal tunnel syndrome ( A painful compression of the median nerve as it passes through the wrist)
Yes
No
Nervous agitation (in ability to relax)
Yes
No
Repeated tapping of the hands or feet.
Yes
No
Are you easily disoriented and/ or confused?
Yes
No
Do you have high blood pressure?
Yes
No
Do you have chronic diarrhea or sloppy stools?
Yes
No
Are you easily weakened by stress or are you physically intolerant to stress?
Yes
No
Do you have chronic arthritis?
Yes
No
Do you have heart disease and / or angina pectoris (pain on your chest as a result of heart problem)
Yes
No
(Women) Do you suffer from headaches occurring prior to or during your menstrual cycle?
Yes
No
Do you have overactive or underactive thyroid function?
Yes
No
Do you have osteoporosis (bones that are fragile and fracturing due to loss of calcium)?
Yes
No
Do your bones fracture easily, or do they fail to heal after fracturing?
Yes
No
Do you suffer from epilepsy or convulsions?
Yes
No
Do you drink alcohol on a daily basis?
Yes
No
Do you have history of kidney stones?
Yes
No
Do you suffer from chronic kidney disease?
Yes
No
Do you regularly take diuretic drugs? (drugs to make you pee a lot)
Yes
No
How many teaspoons of sugar do you put in an 8 oz cup and how many cups of tea or coffee do you drink per day?
Yes
Other
Do you drink distilled water 2 or more glasses per day?
Yes
No
Do you consume candies or sweets daily?
Yes
No
Do you eat refined sugar hidden in foods like cookies, chocolate, etc?
Yes
No
Do you eat white flour and white rice products?
Yes
No
Do you drink one or more alcohol beverages daily?
Yes
No
Do you smoke ½ pack or more of cigarettes per day?
Yes
No
Do you use chewing tobacco?
Yes
No
Do you drink pop daily?
Yes
No
Do you take Aspirin on a daily basis?
Yes
No
Do you take Tagamet or Zantac on a daily or weekly basis?
Yes
No
Do you use antiacids on a daily basis?
Yes
No
Do you use laxatives (to help you with bowel movements)?
Yes
No
Do you take tetracycline drugs?
Yes
No
Do you have a family history of heart disease or diagnosed with coronary artery/heart disease?
Yes
No
Do you have high blood pressure above 140/90?
Yes
No
Do you have chronic diarrhea , crohn’s disease or ulcerative colitis?
Yes
No
Do you leg cramps?
Yes
No
Do you snore excessively or experience sleep apnea (stopping to breath while asleep )?
Yes
No
Do you work with heavy metals, i.e. cadmium, mercury, lead etc?
Yes
No
Have you had one heart attack in the past decade?
Yes
No
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