MS-7025-2-En

7025-2--EN

Section 1 – Personal and Demographic Information

Full Name(Required)

Age(Required)

Gender (Required)(Required)

Male

Female

Other

Marital Status (Required)(Required)

Single

Married

Other

Number of Children

Date of Birth (MM/DD/YYYY)

Registration Date (Required) (MM/DD/YYYY)(Required)

Phone Number (Required)(Required)

Email (Optional)

Place of Residence

City

Village

Climate of Residence

Hot

Humid

Cold

Dry

Height (cm)(Required)

Weight (kg)(Required)

Blood Group

Section 2 – Occupational and Environmental Conditions

Job / Occupation

Exposure to Dust

Yes

Exposure to Chemical Materials

Yes

Notes about workplace environment (air quality, temperature, physical load)

Section 3 – Main Complaint and Disease Onset

Onset Date of Symptoms (MM/DD/YYYY or approximate)

Description of Onset

Gradual

Sudden

If gradual, please explain the course (please specify)

Cause of Onset / Initial Trigger (if known)

Reason for seeing a doctor(Required)

Previous medical results or diagnosis related to this condition

Describe your current complaints, discomforts, physical symptoms, and conditions(Required)

Section 4 – Medical History

4.1 Past Medical History

Past Medical History (Check all that apply)

If 'Other chronic illness', please specify

4.2 Surgeries and Procedures

Surgeries and invasive procedures (type and date)

4.3 Previous Severe Illness or Infection

Serious infections or hospitalizations in the past

4.4 Infectious / Viral History

History of viral or contagious diseases in the past

4.5 Allergies and Sensitivities

Allergies (type)

Medication

Food

Insect bite/sting

Reaction Description (hives, swelling, anaphylaxis, etc.)

Section 5 – Current Symptoms (Systematic Review)

A) General Symptoms (Required)

General Symptoms(Required)

Severe Fatigue

Muscle Weakness

Numbness or Tingling

Muscle Cramps

Pain

Abnormal Sweating (Excessive or Low)

Weight Loss

Weight Gain

Heat or Cold Intolerance

B) Motor and Muscular Symptoms (Required)

Motor and Muscular Symptoms(Required)

Difficulty Walking / Loss of Balance

Tremors (Hands / Legs)

Weakness in One or Multiple Limbs

Frequent Falls

Difficulty Moving Large Muscles

Reduced Ability in Daily Activities

C) Visual Symptoms (Required)

Visual Symptoms(Required)

Blurred Vision

Double Vision

Pain Behind the Eye

Reduced Visual Field

Poor Vision in Low Light

D) Cognitive and Psychological Symptoms (Required)

Cognitive and Psychological Symptoms(Required)

Difficulty Concentrating

Short-term Memory Problems

Slowed Information Processing

Impaired Decision-making

Difficulty Organizing Tasks

Depression

Anxiety

Severe Mood Changes

Feeling Restless or Empty

E) Speech and Swallowing Symptoms (Required)

Speech and Swallowing Symptoms(Required)

Difficulty Speaking

Difficulty Swallowing

Changes in Voice

Voice Tremor / Lack of Coordination

Feeling of Choking While Eating

F) Urinary and Digestive Symptoms (Required)

Urinary and Digestive Symptoms(Required)

Bladder Control Problems

Frequent Urination

Urinary Retention

Constipation

Diarrhea

Digestive Problems

Section 6 – Headache and Attack Characterization

Do you experience headaches?(Required)

Yes

Frequency

Rarely

Sometimes

Often

Always

Severity

Mild

Moderate

Severe

Very Severe

Type / Character

Migraine-like

Burning

Pressing

Pulsating

Location

Back of Head

Front of Head

Temples

Top of Head

Whole Head

When do headaches usually occur?

Mornings

Afternoons

Nights

After Meals

When Hungry

During Stress

With

Numbness

Dizziness

Do you experience increased blood pressure during headaches?(Required)

Yes

If yes, how much? (mmHg)

During headache(Required)

I feel head heaviness

Accompanied by nausea and fatigue

Accompanied by a feeling of warmth

How and with what methods does your headache improve? (Rest, medications, cold/warm compress, dark room, etc.)

Section 7 – Attacks and Exacerbations (General)

Most Frequent Attacks or Current Issues (statement and explanation)

Since what date/age did these attacks begin? (approximate)

Onset of attacks

Gradual

Sudden

If gradual, explain

Temporal Pattern of Attacks

Weekly

Monthly

Seasonal

Yearly

Attack Intensity (from 1 to 10)

Aggravating Factors

Food

Heat

Cold

Movement

Stress

Light

Relieving Factors

Rest

Heat

Cold

Food

Symptoms Accompanying Attacks

Dizziness

Heart Palpitation

Weakness

Urgent Urination

Low Energy

Blood in Mucus

Characteristics of Previous Attacks (time, frequency, color, shape, size)

Have you ever had such an attack before?

Yes

If yes, when?

Section 8 – System-based Symptom Checklist

Skin

Itching

Bruising

Acne

Bleeding from mucous membranes

Color change

Bones and Joints

Joint pain (Forearm / Knee / Spine / Other)

Back pain

Digestive

Diarrhea

Constipation

Nausea

Vomiting

Heartburn

Blood in stool

Where is the pain located?

Urinary

Bloody urine

Incontinence

Frequency

Reduced urine volume

Burning urination

Respiratory / Cardiac

Shortness of breath

Cough

Wheezing

Heart palpitations

Sensory / Neurological

Tingling

Numbness

Pins and needles

Muscle weakness

Dizziness

Ear-related

Ringing in ears

Imbalance

Buzzing

General Condition

Weight loss

Abnormal weight gain

Severe fatigue

Fever and chills

Body temperature (°C)

Warning Indicators

Section 9 – Kidneys, Urinary Tract, and Stones

Burning during urination

Duration of burning

Urinary infection

Mild

Severe

Duration

Kidney stone size (mm)

Location of kidney stone

Right

Left

Section 10 – Psychological and Emotional Status

Depression, self-harm thoughts, or suicidal ideation

Yes

Explanation

Social support — Do you feel isolated or supported?

Mood changes / alterations in emotional state or behavior

Emotional states during anger

Sensitivity

Irritable

Touchy

Do others say your mood has changed? How?

Have you been exposed to stressful or worrying events? If yes, describe.

Mood states

I am happy

I used to be very happy

I feel depressed

I have recently become depressed

I am optimistic

I am pessimistic

I overthink a lot

Crying without reason

Low

High

Excessive

Social type

I am social

I am withdrawn and isolated

I am introverted

I am talkative

Despite being calm, I get irritated

Relationship with others

Very strong

Somewhat

Average

Weak

Compatibility with spouse (if applicable)

Very compatible

Somewhat

Average

Weak

Emotional or verbal abuse

A little

A lot

Very much

Reasons for sadness or depression

Financial problems

Family issues

Educational issues

Work-related issues

If there is a specific reason, please mention

Feeling of numbness, indifference, or unexplained excitement

Yes

Very little

A lot

Constant

Without reason

Accompanied by insomnia and depression

Only after anger/stress/anxiety

Section 11 – Sleep

Amount of sleep

Low

Average

High

Very high

Ease of falling asleep

I fall asleep late / with difficulty

I fall asleep easily

How many hours do you sleep at night?

From what time to what time?

How long do you sleep after lunch (afternoon nap)?

Sleep quality

Very light

Light

Normal

Heavy

Very heavy

Good and peaceful

With disturbing dreams

Memory status

Strong

Good

Average

Weak

Very weak

Recently weakened

Since when has your memory weakened?

Section 12 – Diet, Thirst, and Temperature

Thirst

High

Low

Normal

Desire for cold drinks

Yes

Desire for hot drinks

Yes

Pattern of thirst

I have no desire to drink water

Very low

Low

Medium

High

Very high

When exposed to heat or thirst, I don’t drink water but I drink tea

How many glasses of water per day?

Tea per day?

Beverages/syrups per day?

Milk/dairy per day?

In winter?

In summer?

Do you follow a specific diet?

Yes

Description (diet)

Have you followed a strict diet in past years?

Yes

Description (strict diet)

What food sources do you consume the most?

General preferences

I prefer sweeter foods

I prefer salty foods

Tendency to consume sweets

Amount of sweet consumption

I like sweets but avoid consuming them

Yes

Compatibility of sweet consumption

Very compatible

Somewhat incompatible

Not compatible at all

Tendency to consume warm foods

Low

Medium

High

Very high

Level of warm-food consumption

Compatibility with warm foods

Fully compatible

Somewhat incompatible

Not compatible at all

Common warm foods you consume

Level of pepper and spice consumption

I do not consume

Very low

Low

Medium

High

Not compatible at all and I avoid it

What effects or heat sensations do warm foods cause for you?

Sensitive to cold

Yes

Sensitive to heat

Yes

Body type

Slim and active

Medium and warm

Strong and slow

Organ features (self-perception)

Appetite

Sleep

Skin

Weight

Does season or weather change worsen symptoms? Which season?

Section 13 – Lifestyle and Routines

Tendency to activity and thinking speed

Fast

Medium

Slow

Does warm temperament or burning symptoms increase?

Yes

Your routines

Meditation

Yoga

Exercise

Swimming

Walking

None

Section 14 – Current and Recent Treatments

Current medications (Week Two, times per day) — including prescribed, OTC, supplements, herbal

Medications recently taken (last 36 hours)

Recent vaccinations or treatments (antibiotics, steroids, biologics)

Recent reactions to medications/treatments

Immune-modulating treatments / Complementary therapies

Homeopathy

Ozone therapy

Traditional medicine

Other (describe)

What care and follow-up have you had so far?

Section 15 – Treating Physician and Availability

Doctor’s Name(Required)

Doctor’s Phone Number(Required)

Doctor’s Diagnosis(Required)

Doctor’s Recommended Treatments(Required)

For starting a treatment protocol, I have one-week physical availability in the UAE(Required)

I have

I do not have

Section 16 – Documents Upload

Upload medical reports, imaging, lab tests, prescriptions, etc.

Upload Documents (Drop files here or select files – Max. 30 MB)

Drop files here or

Max. file size: 30 MB.

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7025-2--EN

Section 1 – Personal and Demographic Information

Section 2 – Occupational and Environmental Conditions

Section 3 – Main Complaint and Disease Onset

Section 4 – Medical History

4.1 Past Medical History

4.2 Surgeries and Procedures

4.3 Previous Severe Illness or Infection

4.4 Infectious / Viral History

4.5 Allergies and Sensitivities

Section 5 – Current Symptoms (Systematic Review)

A) General Symptoms (Required)

B) Motor and Muscular Symptoms (Required)

C) Visual Symptoms (Required)

D) Cognitive and Psychological Symptoms (Required)

E) Speech and Swallowing Symptoms (Required)

F) Urinary and Digestive Symptoms (Required)

Section 6 – Headache and Attack Characterization

Section 7 – Attacks and Exacerbations (General)

Section 8 – System-based Symptom Checklist

Skin

Bones and Joints

Digestive

Urinary

Respiratory / Cardiac

Sensory / Neurological

Ear-related

General Condition

Warning Indicators

Section 9 – Kidneys, Urinary Tract, and Stones

Section 10 – Psychological and Emotional Status

Section 11 – Sleep

Section 12 – Diet, Thirst, and Temperature

Section 13 – Lifestyle and Routines

Section 14 – Current and Recent Treatments

Section 15 – Treating Physician and Availability

Section 16 – Documents Upload