Confidential Patient Form · Kushal Clinic

01

Patient details

Full name *

Age *

Sex *

Female Male Other

Marital status

Occupation

Height (approx)

Weight (approx)

Mobile / WhatsApp *

Email (optional)

02

Your main concern

What is your main problem? *

Since when has it been present?

How did it begin?

How much does it trouble you? (1 = mild, 10 = unbearable)

MildUnbearable

What do you expect from the treatment?

03

Details of your complaint

Where exactly is the problem?

How does it feel?

How often does it occur?

At what time is it worse?

What makes it worse?

What gives relief?

Any associated symptoms?

+ My main complaint is acidity / gas — open this section

I get

Worse from

Improves by

Which foods do not suit you?

What foods do you crave?

04

Appetite & food habits

Appetite

Thirst

Low Moderate Excessive

Cravings

Foods disliked

Foods which disagree

05

Bowels, urine & sleep

Motion / bowels

Urination

Quality of sleep

Dreams

Preferred sleeping position

06

Generals

Do you feel more hot or chilly?

Hot Chilly Both

Energy level (1 = very low, 10 = full of energy)

Very lowFull of energy

Sweating

07

Mind & emotions

These are some of the most useful questions in homeopathy. Please be as open as you feel comfortable.

How would you describe your nature?

What worries you most?

Any fears?

How do you react when angry?

Any major stress, grief or disappointment before the illness started?

08

Past & family history

Major illnesses

Operations

Hospital admissions

Injuries

Family history (tick any that run in your family)

09

Current medicines

Allopathic medicines you take now

Supplements

Previous treatment taken

10

For female patients

Optional — please fill what is relevant to you.

Menstrual history

Menopause

Pregnancy history

11

Anything else & reports

Anything else you would like to share

Attach previous prescriptions, blood reports or scans (optional)

Photos or PDFs. You can also bring them to your appointment if it is easier.

📎

Tap to attach or drop files here

Up to 12 files · 30 MB total

Patient details

Your main concern

Details of your complaint

Appetite & food habits

Bowels, urine & sleep

Generals

Mind & emotions

Past & family history

Current medicines

For female patients

Anything else & reports

Thank you