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Step 4. Patient's Questionnaire
PLEASE READ THIS FIRST BEFORE FILLING THIS FORM
Kindly fill out this questionnaire only after you fill out the Preliminary Data.

For accurate assessment and treatment, a detailed case history is required. Kindly fill out the following questionnaire and include as many details as possible. Once you are satisfied with your answers, click ‘Submit’ at the end of the questionnaire.

If you have any queries while filling out the questionnaire, you may call us on +91 9930363981
(We advise you to read the questionnaire carefully before you begin filling it out)

1.   Personal History:

Patient Name :
 
Date of Birth :
(mm/dd/yyyy) 
Age :
 
Sex :
Marital Status :
Email :
 
Skype ID :
 
Address :
 
Occupation :
 
Birthplace :
(City&Country)  
Height :
Inches  
Weight :
(lbs or Kg)  
Referred by :
 
Preferred Language for consultation :
1.      2.  

2.   Chief Complaint :


Describe every symptom in detail :
 
Onset :
 
Duration since :
 
Diagnosis,if any, made by physician :
 
What worsens / eases these symptoms ? :
 
Associated Complaints :
 

3.   General information :


(a.)  Appetite:
Tendency to indulge in certain foods :
 
Any particular likes/dislikes for food? :
 
Any particular likes/dislikes for food? :
 
(b.)  Thirst:
Thirst:How much thirst do you have? :
 
Any particular time are you specially thirsty ? :
 
(c.)  Temperature:
More tolerant to :
 
Weather you are most comfortable in:
 
(d.)  Perspiration:
profuse/scanty? :
 
Do you perspire on the palms or soles? :
Is the sweat warm, cold, clammy, sticky, stiffens the linen etc.? :
What is the smell like ? e.g. foul, pungent, sour :
 
(e.)  Urine:
Any problem about urine ? :
Any strong smell? Like what ? :
Do you have any trouble before, during and after passing urine ? :
 
(f.)  Bowels:
problem regarding your stools? :
Any strong smell? Like what ? :
 
Do you have any trouble before, during and after passing stool ? :
 
(g.)  Sleep:
Quality of sleep :
 
Activity in sleep :
Describe if anything else is unusual about your sleep: (Sleepy, Sleeplessness, etc. if so when)
 
How much do you cover ?
 
Dreams :
 
Allergic Reactions :
 
Sensitivity :
Your Habits How Much ?
Smoking
Snuff
Chewing tobacco
Alcohol
Tea
Sleeping Pills
Laxatives / Purgatives
Any other  
Past Hospitalizations/ Surgeries/ Injuries :
Diseases suffered from Approximate Age Duration Whether you completely recovered Medicines & treatment taken Any other particulars
Mention any drugs, tonics, stimulants etc. that have been used by you at any time in life

At present is on medication / any illness :

4.   Family history :


Relationship Diseases suffered/at age

5.   FOR WOMEN :


(a.)  Menses :

How are the periods; regular or irregular . At what age did you start :

Was there any trouble then . Mention Mention number of days of flow :
(b.)  Menstrual flow :

Is there any change now in quantity, color, smell or consistency :

Are the stains difficult to wash :

Are the stains difficult to wash :

Do you suffer in any way before, during or after menses If so, describe :

Is there any white discharge If so, mention the nature, color, consistency and smell of discharge :

Any itching, excoriation etc. due to discharge Any trouble with breasts :
(c.)  Pregnancy History / Obstetric History :
Number of children :
Any drug intake during pregnancy. What were they :
Any contraception used :
Any abortions, miscarriages or still births :

Please write in detail, if the mother suffered from any physical or emotional stress during pregnancy. Also describe the dreams the mother got during pregnancy :

6.   FOR MEN :



Any difficulty in erection ? :

Wanted erection ? Unwanted erection ? :

Weak erection ? Failing erection? Describe :

Any other trouble in sex ? Describe in details :

Did you have increased desire or decreased desire for sex ? :

6.   MIND :


It is now universally acknowledged that your mind has tremendous influence on your body.
For giving proper treatment it is absolutely necessary for us to understand your emotional and intellectual nature. We can thus treat you as a whole.
In order to understand you we will be asking certain questions. Answer them freely, carefully and completely. This information will help us much in giving you the correct remedy. Also such a remedy will help improve your mental make up.
Answer freely. Answer frankly. Answer completely.

Childhood Nature :
 

Basic Nature :
 

Relation at home ? :
 

Are you anxious ? About which matters ? :
 

Are you fearful of anything such as animals, people, being alone, darkness, death, disease, robbers, sudden noises, thunder, of the future, of something unknown, high places, etc. ?:
 

Are you doubtful or suspicious? Of what ?:
 

what are you jealous about ? Of whom? From what symptoms do you suffer when jealousy ?:
 

In which matter are you impatient ? / Hurried ?:
 

How long do you remember hurts caused to you by others ?:
 

How much revengeful are you ?:
 

Get easily hurt ?:
 

Depress, Brooding, etc. ?:
 

Do you ever become suicidal ? When ? If so in what manner do you contemplate to end your life?:
 

Even then, are you afraid of dying ?:
 

When are you cheerful ?:
 

Any unwanted thoughts any time ? What are they ?:
 

Have you any imaginary sensations or fears ?:
 

Do you hear voices, or that you are called, or anything else in this line keeps on occurring in your mind unduly ?:
 

How is your memory ? For what is it poor? e.g. names, places, faces, what you have read, etc.:
 

Do you weep easily ?:
 

What makes you weep ?:
 

How do you feel after weeping ?:
 

How do you feel if someone offers sympathy and consolation ? :
 

Are you easily irritated ? :
 

What makes you angry ? :
 

What bodily symptoms do you develop when angry ? e.g. trembling, sweating etc :
 

Do you like company ? Or like to remain alone ? :
 

How seriously are you affected by disorder and uncleanliness in your surrounding ? :
 

What are the greatest grief that you have gone through in your life ? :
 

What are the greatest joys that you have had in life ? :
 

What activities you deeply like ? :
 

Are there any matters which you deeply dislike ? :
 

In your opinion, which aspects of your mind and moods are not agreeable to you. Inspite of your awareness and maturity, are you unable to change these aspects ? :
 

Give a clear cut picture of your situation in life and your relationship with each of your family members, friends and associates in work:
 

How does the future look to you ?:
 

When you are free, what thoughts come to your mind ?:
 

Are you worried or unhappy over any personal, domestic, economical, social or any other condition ?:
 

If so describe in detail :
 

If asked for 3 desires or wishes in life, what will you ask for ? :
 
     








Disclaimer: Online consultation gives you a chance to receive treatment that may not be possible to access in any other way. We do not guarantee you the results you may desire and will not be held responsible for the outcome of your treatment. Also, homeopathic remedies are non-toxic, safe and do not produce any side-effects. Any adverse health events that may occur must not be associated with your homeopathic treatment and we take no responsibility for these, if any.

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