Questionnaire

Date of recording:

Patient’s Name:

Age:

Sex:

Married / Bachelor / Widow / Widower:At what Age:

Postal Address:

Country:

Telephone No:

Fax No:

E-Mail:

Appearance:

  • Complexion :
  • Height :
  • Weight :

1. Chief Complaints:

  • Please write in details, in separate paragraph, about the exact Nature of the Complaints, with Location, Sensation, condition of Modalities (i.e. better by or worse by) as regards time, position, relation to heat and cold, season, time etc.

2. Other Complaints:

  • If any, please write in details as above in separate paragraph.

3. Duration & History of Present Complaints including the Previous Taken Treatment:

4. Family History:

A. Please write about the diseases your parents, grand parents and relatives on maternal & paternal side had suffered from, including your other blood relations like paternal / maternal uncle & aunty.

B. Any history of the following diseases in your blood relation both of maternal and paternal side :

Headache / Meningitis / T.B. / Pleurisy / Nephritis / B.Coli / E.Coli / Epilepsy / Skin disease / Asthma / Venereal disease / High blood Pressure / Cancer / Fistula / Diabetes / Ulcer / Piles/ Rheumatism / Insanity or Mental Disease/Hypertension or any Heart trouble / Any other sufferings.

C. Any History of Suicide in your blood relations?

D. Mother / Wife:

  • Any History of Abortion / Miscarriage of your mother or wife? Give cause.
  • Any history of Stillbirths / Premature death?

5. History of Past Ailments:

A. Please write about the diseases you have suffered from, in your childhood and in the recent past, in a sequential order of age. Also please mention about hospitalisation & history of receiving blood transfusion, if any.

B.When you are in mothers womb had she been suffering from any kind of disease or was she got any fright or shocked or accident?

C.Were you born in due time? Were you able to walk in time, were your dentition in due time, did your Fontanalies (Scull) join in time?

D. Whether you had been suffering since your birth from:

  • Whooping cough / Pneumonia / Bronchitis / Measles / Chicken pox / Diarrhea / Dysentery / Malaria / Diphtheria / Venereal disease / Tonsillitis / Mumps / Throat trouble / Diabetes / Piles / Fistula / Jaundice / Hepatitis / Plurucy / T. B. / Rickets / Black-fever / Typhoid / Rheumatic trouble / Epilepsy / B.Coli / E.Coli / Hypertension or any Heart trouble / Cancer or any other diseases.

E. Had you been suffering from any sort of Skin disease?

  • What was there character, location, sensation, type, such as itching, eruption, ulceration?
  • What kind of treatment was taken?

F. Any history of Injury / Accident? In which part of your body?

  • Any bad effect of that?

G. Any history of bite by Snake / Dog or any other poisonous animal or insects?

  • Had you taken full proper treatment?
  • Any bad effects?

H. Any history of Mental shock?

  • Write details about that?
  • Any bad effects?

I. Have you taken Vaccination, Inoculation, Triple antigen, A.T.S., B.C.G., D.P.T., M.M.R., Polio vaccine, X-ray, Radium therapy etc. since your childhood?

  • Have you ever suffered from reaction to any of them?

6. Personal History:

Please write about the habits, regular use of medicines of any type, such as tonics, sleeping pills, purgatives etc:

  • Any bad habit :

A. Sexual Relations:

  • Desire, frequency, relation to chief complaints, if any :
  • Any peculiarities or any problem?
  • Any history of masturbation?
  • Do you have Nymphomania / Quick seminal discharge / Impotency / Libidinous?

B. Urine:

  • Quantity frequency & associated complaints (If any) :
  • Stream :
  • Odor :
  • Any sort of pain or history of burning before/during/after urination :
  • Any history of bleeding/pus discharge with urine :

C. Stool:

  • Frequency, consistency & associated complaints (if any) :
  • Time required :
  • Odor :
  • Is there any blood or mucous with stool :
  • Any history of constipation / dysentery / diarrhea since your childhood?
  • Have you any trouble of flatulence, fart, eructation, acidity? In what time it aggravates and ameliorates?
  • Do you regularly evacuate the bowels immediately after getting up from bed?

D. Worms:

  • Have you ever had any worm or any other parasitic infestation in the past?
  • if yes, please give details :

E. Skin:

  • Please mention your skin type (e.g. dry / oily) :
  • Do you have warts or moles on any part of the body?
  • Had you excessive growth of hair on parts of your body?

F. Appetite:

  • More / less / moderate :
  • You feel hungry extremely specially in what time?

G. Desires:

  • Your likings of the food / drinks / edibles as regards taste, warm, cold etc.
  • Please mention if there is history of any abnormal desires such as Ash, Earth, Lime etc.
  • Are you vegetarian or not?
  • If not, you are given three item - meat, fish, egg - what do you prefer first?
  • Do you need extra salt with your daily food?
  • Sweets / Salty - what kind of food you prefer excessively?
  • Are you prefer/digest milk?
  • Are you cravings for sour thinks?

H. Aversion:

  • What are the types of Food / Drinks for which you have dislike?
  • Are you able to digest green leaves?

I. Disagrees:

  • Do any specific food articles or drink precipitate any problem?

J. Thirst:

  • More / less / medium :
  • Quantity at a time :
  • Do you feel that there is excessive salivation in your mouth?

K. Thermal Relation:

  • Your likes / dislikes & reactions about the season, such as tolerance / intolerance to heat, cold, rains, humid weather etc.
  • How do you relish the open air?
  • What is the type of clothing you like for regular use?
  • Do you experience burning sensation in any part of the body? If yes, give details.
  • Have you tendency to catching cold?
  • If you wet in rain, what will effect?

L. Sleep:

  • How is your sleep?
  • Write in details including the position during sleep.
  • Any history of long continued insomnia since your childhood :

M. Dreams:

  • Do you have any specific dreams like - of fear, snake, dog, flying, falling from height, examination, expired relatives, thief, murder etc?
  • If yes, write the details and the frequency of the same.

N. Perspiration:

  • How do you sweat?
  • What is the amount of sweat (Mild/moderate/profuse)?
  • Is it more on some particular part of the body?
  • Does it stain?
  • Do you feel better after perspiring or feel worse?
  • Is their any peculiar odor?

O. Salivation:

  • What do you feel - dryness or wet on your mouth?
  • Do you feel that there is excessive salivation in your mouth?
  • Does the saliva dribble during sleep?
  • Is there any offensive odor?

P. Wounds:

  • Does your wound heal readily or have a tendency to suppuration?
  • Do you feel that the bleeding from the wounds is normal in quantity?

Q. Life space:

Please write a short synopsis about you as a person along with details of your family background, school & college education, business or job satisfaction etc. With an emphasis on any such event in your life which you feel have any relation with that of the evolution of your present state of illness.

7. Mental History:

  • Temperament: Momentary / violent / consolation aggravates / sulky.
  • Behavior:
  • Fear: In what subjects please specify:
  • Home sickness / Introvert / Extrovert:
  • Intellect / Talent: Normal / Witty / Sharp-witted / Stupid
  • Memory: Normal / Weakness /Forgetful
  • Concentration: Normal /Absent minded / Abstraction /Difficult
  • Suspicious / Distrustful:
  • Mania / Ludicrous:
  • Fastidious / Untidiness / Cleanliness:
  • Wanted with company / alone:
  • Music: Like / dislike.
  • Talking / speech: Normal / less /loquacity / any abnormalities.
  • Shy / Shameless / Lewdness:
  • Thinking - on what subjects?
  • Calculative / Economic / Extravagance:
  • Any History of suicidal tendency:

8. For Female Patient only:

A. History of Menstrual Cycle:

Please write in detail about:

  • Age of Menarche :
  • Regularity of the cycles :
  • Duration :
  • Quantity :
  • Nature of discharge :
  • Symptoms before, during and after menses :
  • Last menstrual period :

B. Leucorrhoea, or any other abnormal discharge, (if any):

  • Its nature : Hot / cold :
  • Character : Watery / Pasty / Thinly / Thickly / Ropy / Excoriated the parts:
  • Odor :
  • Color :

C.Obstetrical History:

  • Number of children with age:
  • Type of delivery with complications, if any:
  • History of abortions, if any (Natural or Induced):
  • Whether have undergone surgery for family planning?
  • If not, methods adopted for family planning:

9. Radiological / Pathological Findings:

  • Blood:
  • Stool:
  • Urine:
  • E.C.G.:
  • E.E.G.:
  • Ultrasonography:
  • Scanning:
  • X-ray:
  • Others:

1