Healing You Naturally
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
1. 2. 3. 4. 5. 6. <h6><strong>Are you intolerant or allergic to anything you are aware of?</strong></h6><br /> 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.