Patient Case Form Basic Information Email * Name * Age * Weight and Height Allergies (if any) Medical History Present Complaints (mention symptoms in detail) * Past History (surgery or illnesses) Family History (Diabetes, cardiovascular disease, other illness etc.) Present Medications Lifestyle & Diet Describe Regular Food & Timings Throughout the Day Describe Your Average Day Lifestyle Addictions or Habits (if any) Physical Stress Level None Low (1-3) Moderate (4-6) High (7-10) Emotional Stress Level None Low (1-3) Moderate (4-6) High (7-10) Physical Characteristics Skin Texture Select… Oily soft Dry rough Changes Complexion Select… Fair – Even Fair – Freckles Brown Dark Hair Texture Select… Soft thin Soft thick Rough thin Rough thick Hair Color Select… Black Brown Light brown Hair Greying Select… Late and slow Early but slow Late but fast Early and fast Not applicable Scalp Select… Healthy Itchy Dry scaly Oily Teeth Select… Even in row Uneven Large and even Large and uneven Teeth Health Select… Healthy Cavities Pain/sensitive Dental treatments often Eyes Select… Large Medium Small Eye Color Select… Black Dark Brown Light brown Other Fingers Select… Long Average Very small Nail Bed Select… Well formed Small Other Nails Select… Strong Brittle Nails Condition Select… Normal Discoloration Cracks Tongue Select… Always Coated Gets clean easily Minimal coating Tongue Condition Select… Normal Discoloration Ulcers Other Body Structure Musculature Select… Well formed Lean Muscles Select… Firm and healthy Loosely formed Muscle Tolerance Select… Pain and ache easily Can tolerate moderate stress Can tolerate heavy stress Fat Tissue (Adipose Tissue) Select… Excess Average Low Stature Select… Tall well formed Average Short Long Bones Select… Well formed and long Small size Forehead Select… Large (more than four finger width) Medium Small (Less than four finger width) Digestive System Appetite Select… Strong Average Weak Inconsistent Hunger Tolerance Select… Can tolerate Cannot tolerate Digestion Select… Quick Average Takes time more than normal Is Bowel Clear? (check all that apply) Regular timely Irregular Frequent constipation Ill formed stool Loose motion Describe Any Bowel Problems Any Symptoms of Following Often (check all that apply) Excess Flatulence (abdominal Gases) Bloating/Heaviness in stomach and abdomen Burning sour burps Burning sensation in chest General Health & Sleep How is General Health? Select… Fit and good immunity Seasonal illness on off Weak and susceptible to health problems Sleep (check all that apply) Sound and deep Less and alert Less but deep Difficult to fall asleep Sleep Quality (check all that apply) Deep Alert Inconsistent Dreams Select… Regularly many Sometimes few Rarely Emotional & Mental Profile Emotional Responses (check all that apply) Patient Quick Depends on situation Emotional Nature Select… Calm realistic Anxious Careless How Would You Define Yourself Select… Hardworker consistent Ambitious Inconsistent Which is Your Frequent Emotion Select… Being in presence Overthinking Forgetful and changes with situation You Make Decisions Select… Taking time and firm on it Quick and firm Indecisive often Quick but not firm You Are Select… Determinate Brave Underestimates self Memory (check all that apply) Very good Average Weak Food Choices (check all that apply) Hot spicy Sweet cold Comfort Food (check all that apply) Soft semisolid Dry crunchy Submit Form
