Home
About the Center
Acupuncture System of Medicine
Conditions We Treat
Treatment Modalities
Patient Information
Quick Summary
Blog / Resources
Contact Us
Quick Summary
Questionnaire
Name of the Patient
*
Mobile
*
Gender
*
Male
Female
Age
*
Height
*
Weight
*
Address
*
Appetite
*
High
Moderate
Low
Food Habits
*
Vegetarian
Non-vegetarian
If non-vegetarian, how frequent is the consumption?
What do you like in general in food?
*
Thirst
*
High
Moderate
Low
Mention consumption of approximate glasses of water in a day
*
Sleep
Duration of sleep
Bed time
*
Wake up time
*
Do you get deep sleep, or, sleep is disturbed or, anything other peculiar condition?
*
Urination
*
How many times
During the day
During the night
Motion
*
Frequency
Quality
Sweating
*
High
Moderate
Low
Night Sweating
*
Yes
No
Sweating Without Exhaustion
*
Yes
No
Cold Sweat
*
Yes
No
Any particular area which sweats more
Dominant Emotion
*
Anger
Joy
Overthinking
Grief
Fear
Life Style
Edema
Skin
Teeth
Nails
Tongue
BP
Pulse Rate
Addiction (if any):
Dreams
Monthly Cycles (for females only)
Acute Illness(es)
Chronic Illness(es)
History of Illness(es)
Past traumas (emotional/ physical)
Family history of diseases
Submit
© 2022 A U U M Center for Native Medicine. All Rights Reserved. Powered by
Beyondweb Technologies
Home
About the Center
Acupuncture System of Medicine
Conditions We Treat
Treatment Modalities
Patient Information
Quick Summary
Blog / Resources
Contact Us
Enquiry Form
-- Select --
Musculoskeletal Disorders
Postural and Structural Imbalances
Respiratory Disorders
Circulatory and Cardiovascular Issues
Digestive Disorders
Immune System Imbalance
Autoimmune Conditions
Nervous System Imbalance
Neurological Disorders
Urogenital Disorders
Lifestyle-Related Disorders
Stress and Anxiety Management
Hormonal Imbalances
Submit
Enquiry Form
-- Select --
Acupuncture
Electro Acupuncture
Dry Cupping
Fire Cupping
Bamboo Cupping
Wet Cupping
Micro-system Acupuncture
Moxibustion
Guasha Massage
Bone Alignment Therapy
Tok Sen Massage
Hara Diagnosis and Japanese Acupuncture
Magnetotherapy
Colour Therapy
Seed Therapy
Singing Bowl Therapy
Water: The Key to Health and Vitality
Submit
