Abnormal discharge from any part of the body:

Climatic conditions you like:

How do you like your room to be in all Weather conditions:

Do you wrap yourself while sleeping:

Date of last menses:

Menstrual Cycle:

Nature of blood:

Painful:

Tell us when pain increases:

Tell us when pain decreases:

Age in which first menstruation occurred:

Sexual Complaints:

Contraceptive History:

No of Pregnancy:

No of Deliveries:

No of Live birth:

Any Abortions:

No of Deaths:

Complaints associated with menses:

Relief of any symptoms after menses:

Sexual Complaints:

Contraceptive History:

Complications during pregnancy/Delivery:

Any infections or diseases during pregnancy:

Medications during pregnancy:

Type of delivery:

Birth weight:

Milestones-Physical:

Milestones-Mental:

Vaccinations:

Bed wetting:

Night walking:

Grinding of teeth:

Worms:

Mental Symptoms
Please write mental state( includes short tempered, timid,coward,anxiety,confidence level,lazy,rapid,slow etc)
Any serious shock , grief ,
disappointments, fright ,
mental upset , depression or nervous break down

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