Client Assessment Name Your Email Age Place of residence Chief complaints with duration History (origin and course) of this chief complaints How is your Hunger for breakfast? Good Moderate Poor At what time do you take your breakfast? What do you generally take for breakfast? How is your Hunger for Lunch? Good Moderate Poor At what time do you take your Lunch? What do you generally take for Lunch? How is your Hunger for Dinner? Good Moderate Poor At what time do you take your Dinner? What do you generally take for Dinner? Apart from three meals, if you are habituated to taking something else, please explain the time of intake , items generally consumed and frequency intake How much water do you drink? Are you proportionately thirsty to drink this quantity of water? Do you evacuate bowels everyday? How many times & at what time do you evacuate? Do you evacuate with the urge or do you force to evacuate? What is the consistency of the evacuated material? Any other information in this regard? Any specific remarks about your urination? How is your sleep? ( disturbed/Undisturbed) if disturbed, explain the kind of disturbance? How many hours do you sleep and what would be the time of sleeping and time of rising? Other information about your sleep. What is your occupation and what is the nature of your work? Do you have any habits like alcohol tobacco etc? How is your menstrual cycle? Regular Irregular What is the duration if bleeding and the gap between two cycles? Any other information about your menstruation? List of medication that you are currently taking Name of the medicine Write either the generic name or Brand name with mg Method of intake The way in which it is taken. Example - one tablet twice daily after food Medical conditions for which it is suggested Details about the treatments that you have taken for your complaints Name of the treatment Underwent during Special note if any Submit
