Confidential Patient Form · Kushal Clinic

01

Patient details

Full name *

Age *

Sex *

Female Male Other

Marital status

Occupation

Height (approx)

Weight (approx)

Country *

Mobile / WhatsApp *

+91

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?

Heartburn timing

Heartburn symptoms

Acid reaching throat Sour eructations Waterbrash Regurgitation Nausea Burning from stomach upward Burning from throat downward

Heartburn worse after food

Heartburn better with

Reflux position

When did heartburn / reflux begin?

Approximate onset

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

Mind & emotional — detailed

Deeper personality and emotional questions. Optional but very helpful for constitutional prescribing.

What typically causes you to become angry?

How do you usually react when someone disagrees with you?

How sensitive are you to criticism?

Not sensitive Mildly sensitive Moderately sensitive Very sensitive

Which best describes you?

Very organized / fastidious Moderately organized Somewhat careless Very careless

I generally prefer:

Being with people A mix of both Being alone

Your decision-making style:

Quick decisions Careful analysis before deciding Often indecisive Anxious about decisions

Have any of the following significantly affected your health?

09

Thermal state — detailed

Temperature preferences and sensitivities — key constitutional indicators.

Do you prefer:

Summer Winter Monsoon No preference

Temperature sensitivities:

Desire fan most of the time Dislike cold weather Cold hands/feet Hot hands/feet Sweat easily Aversion to fan/AC

During sleep, do you usually:

Cover heavily Cover lightly Remove covers during sleep Kick off covers

10

Food preferences — detailed

Structured food desires and aversions. Strong constitutional markers in homeopathy.

Rate your preference for each:

Item	Dislike	Neutral	Like / Crave
Sweets
Salty foods
Spicy foods
Sour foods
Coffee
Tea
Milk
Eggs
Alcohol
Meat / Non-veg
Fruits
Vegetables

11

Sleep — detailed

Sleep patterns, disturbances and dreams.

Usual bedtime

Usual waking time

Sleep issues:

Any recurring or characteristic dreams?

12

Thirst — detailed

Drinking patterns — quantity, temperature, and changes during illness.

Approximate daily water intake:

Less than 1 L 1–2 L 2–3 L More than 3 L

Preferred drinking pattern:

Large amounts at once Frequent small sips Moderate amounts

Preferred water temperature:

Cold Room temperature Warm Hot

During illness, do you become unusually thirstless?

Yes No Same as usual

13

Perspiration — detailed

Where, when and how you sweat.

Sweat characteristics:

14

Bowels — detailed

Bowel habits and stool characteristics.

Bowel frequency:

Bowel issues:

Stool character:

Hard Soft Loose Variable

15

Past & family history

Major illnesses

Operations

Hospital admissions

Injuries

Family history (tick any that run in your family)

16

Current medicines

Allopathic medicines you take now

Supplements

Previous treatment taken

17

For female patients

Optional — please fill what is relevant to you.

Menstrual history

Menopause

Pregnancy history

18

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

Mind & emotional — detailed

Thermal state — detailed

Food preferences — detailed

Sleep — detailed

Thirst — detailed

Perspiration — detailed

Bowels — detailed

Past & family history

Current medicines

For female patients

Anything else & reports

Thank you