EnrichMentors - INITIAL INFORMATION REQUIRED FOR THE CONSULTATION

Please describe what appears abnormal or peculiar to you from the following checklist. Any additional information which the you think is important but not covered is always welcome & useful

Background ( Tell us everything about yourself)
	Where do you come from	:
	About parents	:
	Occupation	:
	Story of life	:
	Situation regarding marriage, money matters etc	:
1. Chief Complaint
	What are your main complaints ?	:
	Where are your complaints located?	:
	What are the sensations accompanying your complaints ?	:
	What makes your complaints worse ?	:
	What makes your complaints better ?	:
	How and when did these complains begin ?	:
	What symptoms have developed most recently ?	:
	What other illness have you suffered in past? Please describe chronologically	:
	How does this main complaint affect you?
2	Please describe any disorders of vision, hearing, taste or/ and smell	:
3	How is your appetite ?	:
4	Cravings- What food does the individual like very much ?	:
5	What food are you averse of ?	:
6	What food do not agree with you? and How?	:
7	How would you describe your thirst ?	:
8	Please describe color, odor, consistency, size, frequency etc of your stools.	:
9	Please describe the extent, frequency, color, odor, sediments etc of your urine.	:
11	How is your sexual desire ?	:
12	Please describe the frequency, extent, color, odor, consistency etc your menstruation	:
13	At what age did your menstruation begin?	:
14	Please describe the color, odor, extent, consistency etc of vaginal discharges (Leucorrhoea)?	:
16	Please describe your sweat regarding the color, odor, consistency, extent of sweating etc	:
17	How is your sleep ?	:
18	What kind of Dreams do you get?	:
19	What makes you worse in general? Please describe the time of the day, weather, climate, place, situation, activity etc	:
20	What makes you better in general? Please describe the time of the day, weather, climate, place, situation, activity etc	:
21	What are your hobbies? Interests?	:
22	What are your mental make up? Describe the personality	:
23	What do you feel, outside of you, that is urgently threatening?	:
24	How do you react to this urgent threat?	:
25	What do you, outside of you, struggle with to adjust?	:
26	What do you do to adjust to that?	:
27	What in yourself do you feel is lacking?	:
28	How do you do to adjust to this lacking?	:
29	What is outside or inside or you that you feel you must change in order to survive?	:
30	How do you want to bring about this change?	:
31	What situations do you feel happy or comfortable?	:
32	What are the things in these situations you feel happy or comfortable with?	:
33	What are the things you can not help in these situation, despite knowing that they are not good in those situations?	:
34	What are the things in your nature that are socially frowned upon, still you can not avoid?	:
35	When are you angry with yourself?	:
36	What are the things that you can not tolerate or dislike in others?	:
37	Any other things that appears to you as strange, peculiar or abnormal	:
38	Name	:
39	E-Mail (Required)	:
40	Sex	:
41	Height	:	Cms
42	Build	:
43	Anything Else	:
44	Age	:	Years