Computer analysis of case or repertory is done on necessary

Patients name………………………………………………………………… Age……………… (F / M).

Body type………………………………………................................................

Address……………………………………………………………………… Phone…………………..e-mail: ……………………………

The treatment of disease, symptoms or problems for which you have come…………………….

For how many days suffering from above mentioned disease, symptoms or problems………………………………..

What other diseases or problems you have in body…………………………………………………………………………..

Any serious disease which happened before…………………………………………………………………………………

………………………………That disease is fully cured, or still symptoms of disease are seen at present.

Any disease or any injury / accident after which the present description are seen, those
details……………………............…………………………………………………………………………………………….

Any serious disease in the family……………………………………………………………………………………………

Syphilis / Gonorrhea if happened before, how many days before and in what way it was treated……………………………..

All above details according to my knowledge are true. I have known nicely all the knowledgeable items and the rules to be followed (mentioned
below) and agreeing to follow them, willingly, I want my treatment to do here.

Date…………………… Patient's signature………………………

Underline the symptoms which you have

Or

Try to keep the symptoms that suit you better rather than keeping those that doesn’t.

Likes winter / troubled in summer,

Likes summer / troubled in winter,

Dislike both––too much summer–too much winter,

More thirsty / less thirsty,

Thirsty – every time drinks a lot,

Thirsty – Every time drinks little, little,

Wants open air / dislike,

More hunger / less,

Favorite food–– fish / Meet / Egg / vegetable / sour dish / salty / salt / chilly things / sweet / bitter…….,

Un favorite food………………,

Wants food –– hot / cold / warm,

Increase due to eating any food,

Drinks hot / cold / warm,

Favorite drink–– tea / milk / wine / smoking / others……,

Un favorite drink…………,

Mouth –– saliva foul smelling/

saliva discharge during sleep/

ulcer in mouth / tongue/ ……….,

Gum……………………,

Teeth––injury / decay / blackish / pain /

loose teeth / sensitive……….,

Tongue – flabby / dry / with cracks / black / red /white /yellow / foam / scales of skin off / smooth / nodosities /

tongue cannot take out / hardship,

Ear……………………,

Nose…………………..,

Urine –– more / less / frequently / foul smelling / frequently at night / hardship / intermittently (stopping after every little flow) /with burning
sensation / undesirably / senselessly / others…………….,

Piles …………………..,

Stool –– constipation / liquid / hard / hardship in passing out / dry / pasted / sticky / brown / greenish / black / blackish /light color / white /with
foam / with sour smell / with foul smelling / with acidity / with blood / flat / narrow / like ball / like knots / with mucous / big / with eatable
things / coming out in force / with plenty of gas…..,

Sweat –– plenty / less / obstructed / foul smelling / during sleep / after sleeping / after awaking / after closing of eyes /

after drinking / sticky / after meal / after little hard work / increase of symptom of disease due to sweat – relief / sweating of legs / leg sweating
with foul smell / hand sweating / head / the whole body except head / on the throat/ on the face / the whole body except the face / sweat cool /
hot ,

Hand cold / hot /burning sensation,

Leg– cold / hot / burning sensation ,

One hand cold, one hand hot,

One leg cold, one leg hot,

Increase of disease – morning / noon / evening / night / winter / summer / monsoon / autumn / spring / other time / everyday at a fixed time
(getting less / more),

When decrease of disease …………,

Increase of disease –– pressure / heat / cold / after sleep / on movement / drink / food / sweat / during sleep / during rest / others………..,

On what the disease decreases ………,

If any disease before––eczema / ring worm / infection / scabies / syphilis / gonorrhea / tuberculosis (TB) / cancer / asthma / piles / others
………..,

Hereditary diseases …………….,

Right side hardship,

Goes from right to left side,

Left side hardship,

Goes from left to right,

Hardship at corner angles–right side up, Left side down / left side up, right side below,

Once this side ––once other side,

Comes from up to down,

Goes from down to up,

If cuts, suppuration (pus formation) takes place, does not dry up,

Desire to sleep,

Tendency to catch cold,

Homosexual desires,

Clean / dirty,

Increases on new moon day / full moon day / eleventh day of a lunar fortnight,

Not desired to take bath,

Tendency to wash hand frequently,

Wants cover over head,

At the sea side there is increase / relief of disease,

All the secretions / discharge have foul smelling,

Having dreams of: ………………………………………..

Anger –– more / increases or relief on consolation / with vibration / very much / breaks or throwing the things / goes to murder,

Anxiety –– more / while alone / while in bed / pricking of conscience / with fear / about future / about health / before menstruation cycle, –
during ,–that time, –after that time / at night / before the allotted work / during passing of stool –before, –after / others………,

Fear – more / at night / during evening / while alone / in the public / in the darkness / of ghost / of people / fear of death / of forth coming
diseases / dog / animals / others………..,

Other mental symptoms : Restlessness / Obstinate / Lassitude (laziness) / Mild ness / Timidity / Cowardice / Courageous / Dictatorial /
Contradiction / Company, want or want not / Consolation –relief or increase on / Absent mindedness / Affectionate / Suspicious / Censorious /
Contemptuous / hatred ness / Cursing / Destructiveness / Haughty – rudeness – insolent / Home-sickness / Egotism / Hurry / Slow / Impatience /
Irritable / Quite –soft tempered / Offended / Religious / Reserved / Shameless / Sighing / Singing / Weeping / Quarrelsome / Malicious – jealous
/ Lascivious (sexy) / hysteric / Confidence, lack of / childish / Capricious – whimsical / Cares – worried / Death - desires (desires to die) /
Suicide, desire to / Despair / Memory – weak / Delusions (false beliefs) / Talks to own self / Wants to eat or do, that will do harm / Too much
hopeful or hopeless / Love to travel –wants change / Hales light or dark.

Mental Symptoms:
There are so many mental symptoms like these––
Uncontrolled mind / Too much impulsive / Exceedingly or unreal demand / Thought problems / Too much sensual / Confusion / Heedless /
Behavioral problem / Irritability / Helplessness / Impatience / Excited easily / Anxious / Offended easily / Restlessness / Bad tendency / Suicidal
disposition / Suspicious / Exceedingly anger / Superstitious / Home-sickness / Afraid / Aversion to../ Sadness / Emotional / Kleptomania /
Destructiveness / Fanatic/ Mischievous tendency / Contrary …/ Forsaken../ Antagonistic / Sot / Sleep problem / Lac of confidence / Dullness /
Forgetful / Tendency to kill / Timidity / Violent / Wildness / Cruelty / Hopeless / Disobedience / Crazy / Censorious.. etc.