Consultation
Form
Name
Age
yrs
Sex
M
F
Email Id
Height
0
1
2
3
4
5
6
7
Feet
0
1
2
3
4
5
6
7
8
9
10
11
12
Inches
Weight
pounds
Occupation
Details of your home climate
Your Health Details
Name
your disease (as diagnosed by
conventional/modern medicine)
What
are the chief signs, symptoms or
complaints that made you to look at
Unani as an alternative health
solution?
General Diet
Diet
details
Complete History of Disease
Do
your symptoms/complaints decrease or
increase when you change climatic
zones?
What
kind of food, lifestyle or
environmental changes relieve the
nature of your complaints?
Family history
Is any member of your family
suffering from TB, Hypertension,
Asthma, Any allergic disorder, Any
other disease?
Your Treatment History
What
types of treatments and medicines
have you taken so far?
What
have been the results?
Have
you observed any side-effects?
How
much do you know about Unani ?
What
kind of food, lifestyle or
environmental changes trigger the
symptoms of your disease?
Do you any report of investigation
regarding your disease
Digestive System
How is
your appetite and digestion?
Normal
Low
High
Give
complete details of your bowel
movements, such as time of
evacuations, frequency, color,
consistency, regularity,
irregularity and smell.
Do you
see any mucus in your stool?
Yes
No
How
often do you have constipation and
what do you think are the causes?
Do you
pass wind?
Do you have acid reflux/heartburn?
Do you experience heaviness,
discomfort or pain in the stomach
after eating?
Urinary System
What
is the frequency, quantity and color
of your urine?
Do you
feel any burning sensation while
urinating?
Yes
No
Sleep
Do you
sleep soundly?
Yes
No
Mental Condition
How
would you rate yourself emotionally?
Anxious
Nervous
Worrisome
Depressed
Tense
Relaxed
Irritable
Impatient
Patient
Calm
Lethargic
Energetic
Competitive
Driven
Restless
Indecisive
How do
you perceive your own financial
status? What are your comfort levels
with your current situation?
Reproductive System
Mention, if you have any sexual
problems
Are there any other details you
would like to share?
