Registration Form Patient Reference: (For Office user) Date Name * First and Last DOB - Age * Address * Postcode * Email Address * Mobile * Married/Single * No of Children (if any) * Profession * Main Health Issues 1. 2. 3. Since When 1. 2. 3. How did it start or any possible cause you know? 1. 2. 3. Any peculiar physical or * possible cause you know? Any medial suppressions? Any emotional suppression? Any drug suppression? 1. 2. 3. Generalities Generalities Any Family history of? TB / TuberculosisCancerHeart DiseaseTyphoidDiabetesInfectious diseasesMental HealthOther Miasms PsoraSycosisSyphilisTuberculosis Any particular cravings? Salt Sugar Chocolate Coffee Tea Boiled eggs Warm water Cold water Chilled water Junk or oliy food Savouries Others Any Addictions? * Smoking Alcohol Vape Sheesha Street Drugs OtherOther Excessive Vital fluid loss? Modalities any food, weather, move, feeling etc., that makes your health worse. * Anything e.g. food, weather, move, feeling etc., that make your health better. * Feel thirsty Yes No Feeling Hungry Yes No Saliva Yes No Excessive Sweating Yes No Body Temperature Hot Cold Skin type Dry Oily Sensitive Regular Medication Being Taken at Present (if any) 1. 2. 3. 4. 5. 6. <h6><strong>Are you intolerant or allergic to anything you are aware of?</strong></h6> 1. 2. Have you gone through any surgery recently? Yes No If yes, please describe briefly: Captcha Submit If you are human, leave this field blank.
