Patient Form



    Gender:
    Marital status:




    (Anxiety, Fear, Anger, Grief, Sadness, Despair, Weeping, Irritability, Company desire/aversion, Restlessness, Suspicious, Delusions, Suicidal disposition, etc.)

    Timing, Season, Weather, Open-air, Closed-room, Ascending, Descending, Bathing, Sitting-position, Lying-position, Food/Drink- hot/cold, Sleep/Dream, etc.

    Head, Eye, Ear, Nose, Face, Mouth, Teeth, Throat, Stomach, Abdomen, Rectum, Bladder, Male/Female-genitalia, Chest, Back, Extremities, Skin, Hair, Nails, etc.