TTC MEDICAL HISTORY FORM

Please complete the Application Form first and then submit your medical history form. Om Shanti
Full Name
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?
WOMAN ONLY:
Menstruation
Backache
Discomfort Experienced Before/During menstruation
Pregnancy (Number and Duration)
Delivery (Number and Duration)
General Questions:
Do you feel energetic when getting up in the morning?
Do you sleep in the afternoon?
Taking any remedial measures for night sleep?
Do you have vivid dreams while sleeping?
Any interruptions while sleeping?
What is the nature of your sleep?
Do you feel tired at the end of the day?
Can you work with full concentration?
Do you have problems making decisions?
Do you get emotional very often?
Do you have a good appetite?
Do you have regular bowel movements?
Do you take any digestive medication?
Meal Timing: Break Fast
Meal Timing: Afternoon Tea
Meal Timing: Lunch
Meal Timing: Dinner
Daily liquid intake and timings
Date Form Completed
Completed by