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TTC MEDICAL HISTORY FORM
Please complete the Application Form first and then submit your medical history form. Om Shanti
Full Name
Your Email
Do you have an addiction to any substances (please list all)
Previous Surgeries
Date of Previous Surgeries
Previous Major Diseases
Present Physical Complaints
Any Medical Treatments (Current)
Are you experiencing any other problems at this time?
If you have any existing medical conditions, do you have your doctor’s permission to attend this course?
Yes
No
WOMAN ONLY:
Menstruation
Regular
Irregular
Backache
Yes
No
Discomfort Experienced Before/During menstruation
Yes
No
Pregnancy (Number and Duration)
Delivery (Number and Duration)
General Questions:
Do you feel energetic when getting up in the morning?
Yes
No
Can’t Say
Do you sleep in the afternoon?
Yes
No
Can’t Say
Taking any remedial measures for night sleep?
Yes
No
Can’t Say
Do you have vivid dreams while sleeping?
Yes
No
Can’t Say
Any interruptions while sleeping?
Yes
No
Can’t Say
What is the nature of your sleep?
Good
Poor
Can’t Say
Do you feel tired at the end of the day?
Yes
No
Can’t Say
Can you work with full concentration?
Yes
No
Can’t Say
Do you have problems making decisions?
Yes
No
Can’t Say
Do you get emotional very often?
Yes
No
Can’t Say
Do you have a good appetite?
Yes
No
Can’t Say
Do you have regular bowel movements?
Yes
No
Can’t Say
Do you take any digestive medication?
Yes
No
Can’t Say
Meal Timing: Break Fast
Meal Timing: Afternoon Tea
Meal Timing: Lunch
Meal Timing: Dinner
Daily liquid intake and timings
Date Form Completed
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