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Please fill up this questionnaire clearly and carefully without hiding any facts. Register below to receive more information.
( * = Required field.)
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1. Name* |
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2. Age* |
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3. Sex* |
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4. Place of residence: Is it hilly, plain, dry or marshy? Is the house well ventilated ? |
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5. Does he/she take coffee/tea? If yes, how much ? |
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6. Has she/he suffered from any other significant disease in the past? Any previous or present habit of drinking, smoking, or taking drugs? |
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7. Family history: Are your parents alive? If not, of what did they die and at what ages? Any history of asthma, piles, phthisis, neuralgia, hysteria, neurasthenia, epilepsy or insanity in the family either on maternal or paternal side? |
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8. Of what diseases did the patient suffer before and for what period? Any history of syphilis or genorrhea in self, parents or grand parents, wife or husband. Was Gonorrhea or Syphillis cured? What treatment was adopted? |
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9. Any eruptions on the skin, any tumour or warts on any part of the body? If cured, how and when cured. Any discharge from skin disease? Is it thick, watery, bland, excoriating, sticky etc. Give colour, quality, smell, etc. |
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10. Was any operation poerformed on him/her in the past? |
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11. What treatment did you undergo for your present ailment? Give details whether Allopathic, Homeopoathic, Naturopathic etc. with names of medicines used and result. |
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12. What in your opinion was the exciting cause of the first and subsequent attacks, viz. domestic worry, financial loss, fear, anger, over-work, night keeping, loss of semen, working in the sun, run-down health, injury, shock, disappointment, convalescene from typhoid or other diseases, etc. |
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13. Are you fat thin, or plumpy? Emaciated or stout? Any part less developed than other? Any history of delay in learning to walk, talk and dentition. |
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14. Did you uffer from typhoid, measles, small pox, malaria or any similar disease? If so, what was the treatment? Has she been vaccinated? If so how amny times? |
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15. What is your weight? Exactly what time of the day or night does the disease or any particular complaint increase, or decrease and how? Does the disease aggravate by lying or any particular side? which side is preferred to lie on? |
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16. When in company, does she by nature asssume leadership or take a position of less importancde? |
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17. Is there any relation of troubles with day or night, summer, winter, or rainy season, new moon or full moon; or with suppression or cure of any eruption or disease? How was it suppressed? Any external ointment used? |
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19. Is the patient chilly or warm blooded? Like heat or cold? Like open air, like to sleep in a closed room or prefers to lie with doors and windows open? Fond of bathing in cold or hot water? |
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20. Any special craving or dislikes for egg, salt, etc. |
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21. Is there any relation of troubles with day or night, summer, winter, or rainy season, new moon or full moon; or with suppression or cure of any eruption or disease? How was it suppressed? Any external ointment used? |
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22. Sleep: Sound or disturbed, refreshing or not? Sleepless, from what time to what time? Any aggravation or amelioration during orafter sleep. Any dream of cat, snake, robbers, fire, dead people, daily work, floating in the air, etc. Does she put her hands above her head while sleeping, or feel out of the bed? |
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23. Does the attack occur at fixed intervals or does it alternate with neuralgia or any other complaints? |
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24. Menses: early or late, regular, irregular, duration, colour of flow, quantity, clotted or thin, pain if any whewre when how ameliorated? Howe does menses effect the patient's troubles in general? How does menses affects health in general. Give details about delivery, abortions, if any. Are children healthy? |
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25. Head: Heat or burning orn vertex? perspiration on front or back? Itching of scalp, dandruff, falling of hair |
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26. Mouth: Bad odour, salivation, taste? Gums swollen, painful? Teeth carious, coated with tartar, pyrrohea, any grinding of teeth at night? |
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27. Throat: Any pain, right sided or left? Pharyngitis; tonsilitis, chronic enlargement of tonsils with frequent attacks of inflamation |
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28. Eyes: Lachrymation with itching or any pecularity noted. |
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29. Stoppage of nose, which nostril? Watering of nose, itching of nostrils and on nose. |
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30. Ear: Any discharge, thin or thick? State coloour and odour of discharge |
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31. Lungs: Any cough dry or moist, stirring etc. |
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32. Heart: Any palpitation, aggravation from motion of amelioration from it? |
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33. Chest: Did the patient suffer from any disease of chest? |
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34. Sweat: In what part is mostmarked. Is the attack worse or better with perspiration? Any peculiarity regarding sweat. |
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35. Urine: Any bad odour; sediment of what colour and consistency? |
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36. Stool: Colour, odour, four or not? Any ineffectual urging to stool? Is the bowels constipated or loose? |
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37. Hands and feet: Is there any pain or discharge? Any fissure or eruption? any history of piles and whether or bleeding nature? |
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38. Is the patient mild or angry and irritable temper; quarrelsome, fault-finding and obstinate, suspicious of others, jealous? |
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39. Is very talkative or silent, absent minded, cheerful, gloomy or timid? |
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40. Neat and clean, or dirty habits |
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41. Desire to be in company or keep aloof? |
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42. Any fear of death or suicidal tendency? |
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43. Memory weak or active? |
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44. Weeping mood and involuntary sighing; cries when reprimanded or gets more angry? |
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45. Cries for sympathy. |
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46. Keeps busy: wants to do every thing in a hurry or slowly or in a normal manner, very active or dull and backward mentally? |
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47. Any inferiority complex? |
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48. E-mail address* |
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49. Telephone* |
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