PATIENT DETAILS Date

Name: Apurva Male/Female: Female Age: 22 Height:5'3 Weight: 46

● Address: Bangalore Tel No:9424958940 e.mail ID: Apurva.pathak5@gmail.com
Marital Status: single Wedding date:
Children with sex / age
Nationality: Indian Education: Vocation/profession: Student Ref. by:

COMPLAINTS:
1. Suffering for how long: skin hyperpigmentation problem since last 8 years. Only on face
and very mild. It is as it is, and has not spread .
2. Which months/season most troublesome: Winter
3. Which part of the 24 hour day most troublesome: Afternoon 3-5
4. Are you generally constipated: Rarely. After having heavy meals sometimes or when I
drink less water. Otherwise no.
5. Do you suffer frequently from wind in stomach / bloating: Sometimes during night. Never
during the day.
6. Do you frequently suffer from Acidity Never
7. Do you suffer from High or low BP? If yes max. values? No.
8. Do you frequently suffer from colds:
If yes is the discharge watery /thick / stuffy nose Once in a year. Now it is under control. Discharge
is watery becomes thick after medication.
9. Do you frequently suffer from sore throat / coughs? If yes, Once in a year.
Is the cough dry or wet? Wet
Phlegm: colour? Semi transparent. Clear.
Is it frothy / sticky / comes out like a clot? Sticky.
Is it easy / hard to discharge or rattles in the chest? easy to discharge.
10. Do you frequently get headaches? If yes
Do you get nausea? / vomiting?
If yes how do you feel after vomiting? No nausea/ vomiting during headache. Occurs when eyes
get strained. After long exposure to sunlight. Due to certain smells like smell of vehicles. Also
occurs while travelling in closed vehicles like cars, buses, airplanes. Does not happen in autos,
trains.
Location of headache
Type: mostly above the eyes. 80% above the right eye. Left eye rarely happens.
Constant/Throbbing/Pulsating/Piercing ---- constant
11. Are you anaemic? If yes, your haemoglobin count?__12.4__ When checked? __last
year__
12. Do you suffer from sinus? No.
13. Is your eyesight normal? If not, when last checked? Checked 2-3 years back. It was 6/6
then. Power?
14. Do you get pain in the chest? Never.
15. Do you frequently get stomach aches? Never.
16. Is your menstrual cycle normal / abnormal / menopause. Normal.
17. Have you suffered from Piles? No. Never / present / past history
18. Do you smoke? / Drink? / use tobacco? Never / yes / given up. Never.
19. Do you have any known allergies? If yes what? No allergies. Never got tested.
20. Is your sleep Normal / Disturbed / Full of Dreams.
Important: If disturbed or with dreams please describe what you feel or see.
Sleep is normal but sleep cycle is disturbed. Habit of sleeping late and waking up late. I feel more
active at night.
21. Are you stressed, or under tension? No
22. Describe your nature: Easy going / Tense / irritable / Fussy / brooding / Emotional / Quick
tempered / short tempered /
23. Easy going, emotional, very rarely tensed. Tempered sometimes.
24. Any other diseases, ailments that you suffer from? Laziness, lathergy. Constipation only
sometimes but does not last more than 2-3 days.
25. What medications are you on, if any? I was asked to take gomutra ark for my skin disease.
Have just started it 3 days back.
26. Do you do any exercises? No. Just walking to college.
For these highlighted questions you must try and give reasons for them, as YOU see them
Mudras are a holistic form of treatment. I cannot ask questions face to face. All questions are
here for a reason. Please answer all questions in as much detail and with as much frankness and
sincerity as you can. We will save time and effort and I may be able to help you better.
Remember, all data given by you is totally confidential.