attention Dr. Deoshlok Shrama

Full Name: Sudip1967
(You can use your alias if you want to be anonymous)
Sex: M
Age: 43
Weight: 66
Height: 5ft 8 inches
Temperature: normal
Blood Pressure: normal
Color of Tongue: Yellowish with pink on the outer part..
: Bank Employee
Optional Information:
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City:
Country:
Phone:
(With city and country codes)
Email Address:
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Detail Patient History
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Name of Disease:- Indigestion, dysentery, back and rib pain (ankylosing spondylitis), asthma
(Diagnosed by Your Medical Doctor
Or if you know the name of your disease)

Patient Description:- Indigestion, lack of appetite, semi-solid bowel, back pain (controlled by exercise), asthma (controlled by inhaler)
(Important: Write your major complaints
& symptoms briefly in your own words priority wise.)

Cause of your disease / Problem:
(If you don’t know leave it blank)

Period of Disease / Complaints: GERD (periodic – latest from a month), back pain – 3 years, Asthma (since childhood)
(Day, Month or Year when it was started)

Results of major Laboratory Tests:
(Investigations / Pathology Reports)
a.
b.
c.

Comfortable Position:- right side
(Which activity / position / work
make you better and provide relieve
in your disease or problem?)
Worse state of disease:- sitting for al ong time
(Which activity / position or work
when perform make you discomfort
and creates uneasiness or pain?)

Change of Weather:- no.
(Does change in hot and cold
season have any impact on your
disease or symptom?)
Hot & Cold Application:- I like hot water.
(How do you feel in hot or cold
application or when you take bath
or live in warm or cold room)

Good Time: Forenoon
(At what time you feel trouble-free
or comfortable or painless?
Morning / forenoon / evening / night etc?)
Worse Time: Morning..
(At what time you feel uneasiness or discomfort?
Morning / forenoon / evening / night etc?)

Thirst:- Good..
(How is your thirst?)
Appetite:- Bad
(How is your appetite?)

List of medicines used so for:
(Homeopathic and allopathic or Herbal, if any etc)
a. Mag Phos 6 x
b. Nux Vom 200
c. Budesonide and Salbutamol inhaler

Habits:
(Explain in detail where necessary)
Are you addict of alcohol? No
Are you a smoker? No
Are you fond of drinking tea? Yes
Do you like salty/spicy items or sweet stuff? Yes
Are you vegetarian or carnivore? Carnivore
How is your bowel movement? Semi Solid..
on or constipation etc)
Are you slim smart or obese etc? Slim
o you have craving for any food / drink etc?
Do you have any wart or mole on your body?
(First check your body with care) Red Moles in my chest and back
List of your major past illnesses / diseases:-
(examples: Mumps, chicken pox, whooping
cough, pneumonia, malaria, typhoid etc)
a. Chicken Pox -2004
c.


List of major closed family persons diseases:-
(Examples: Asthma, Cancer, Diabetes
High Blood Pressure, Rheumatism or T.B)
a.Asthma (most of my family members are having)

Detail of your past Vaccination Chart:-
(If you remember)
a.
b.
Further Explanation:-
(If not covered above) I feel depressed when I get stomach problem,,,otherwise I am a cheerful person. Another thing I dislike is the burp in the morning with a smeel of previous days dinner.


1. Since two days I am taking Nux Vom 200, with I observed a slight bit has improvement.