### GROW WELL-Height Increasing Program
Case Study Form

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Parent Details*

Address*

Chief Complaints*

Past History of Any Disease:*

Measles
Mumps
Chickenpox
Chicken Gunia
Maleria
Jaundice
Typhoid
Renal Stone
Gall Stone
Heart-Attack
Piles
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### Family History

Father*

Short stature
High Blood pressure
Diabetes
Heart-attack
Cancer
Skin Disease
Obesity
Paternal Grand Father:*

Short stature
High Blood pressure
Diabetes
Heart-attack
Cancer
Skin Disease
Obesity
Paternal Grand Mother: *

Short stature
High Blood pressure
Diabetes
Heart-attack
Cancer
Skin Disease
Obesity
Mother*

Short stature
High Blood pressure
Diabetes
Heart-attack
Cancer
Skin Disease
Obesity
Maternal Grand Father*

Short stature
High Blood pressure
Diabetes
Heart-attack
Cancer
Skin Disease
Obesity
Maternal Grand Mother*

Short stature
High Blood pressure
Diabetes
Heart-attack
Cancer
Skin Disease
Obesity

Developmental History in case of Children*

Milestone Normal
Late learning to Walk
Late learning to Talk

### Obstetric and Gynecological History

For Femals

Menses

Regular
Irregular
Profuse with Clots
Absent
Leucorrhoea

YES
NO
White
Yellowish
Greenish
Offensive Smell

### Generalities

Addiction

Alcohol
Tobacco
Smoking
Gutka
Tea
Coffee
Drugs
Water Thirst*

Normal
Absent
At a Time Small quantity at a small interval
At a Time Large quantity Large Interval.
Desire / Likes*

Sweet
Spice
Sore
Salty
Fruits
Green Vegetable
Bakery Products
Eggs
Fish
Chicken
Meat
Aversion / Don’t like*

Sweet
Spice
Sore
Salty
Fruits
Green Vegetable
Bakery Products
Eggs
Fish
Chicken
Meat
Appetite*

Normal
Increase
Absent

### Bowel Habit

Stool

Regular
Insufficient
Constipation
Stool with Bleeding
Urine

Normal
Increase
Absent
Involuntary Urination
Sleep*

Sound
Increase
Insomnia
Disturbed
Perspiration*

Normal
Increase
Offensive
Relation with Heat and Cold*

Tolerate Cold
Tolerate Heat
Can Tolerate Both
Can not Tolerate Both
Mind / Manasikta*

Sweet
Spice
Sore
Salty
Fruits
Memory ?*

Weak
Medium
Sharp
Anxiety about*

Health
Money
Future
Family
Children
Job
Likes / Dislikes*

Music
Company with friends
Your Nature (Evaluate Your Self)*

Ambitious
History of Disappointment
History of Grief
Perfectionist
Time Punctual
Want Clean Everything
Can Not Tolerate Insult
Can Not Tolerate Injustice
Any Specific Mental Symptoms
Do you have fear of ?*

Darkness
Ghost
Height
Dog
Lizard
Cat
Rat
Insets
Snake
Teacher
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