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Personal Details

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Gender		Female Male
Marital Status		Single Single Happy Single Sad Single Lonely Married Married Happily Married Unhappy Married, but wish was not Divorced Divorced recent Divorced recent, happy Divorced recent, sad Divorced since long Widowed Widowed recent Widowed since long Widowed happy Widowed sad

Medical History

Tell us about your sickness: Tell us about your pain? When do you feel? Frequency of your sickness? If you could think of a reason for this? If you have any previous consultations or medicines, or have run some tests. Try to give as much detail as possible.
How many days/hours does the pain/symptoms/sickness stay?
How many days/weeks/years you have the problem or suffering from it?
Tell us about sickness history in your family like your parents', grand parents' sickness or illness? Give as much detail as possible.