Please fill in this questionnaire in as great detail and as deliberately as possible.
Things that you might feel are "medically not relevant" can give important information, such as your habits, pattern of behaviour, moods etc. Please report things without any inhibition, howsoever, incongruent or irrelevant it may seem.
Include any strange feelings and sensations that you think might be important, even if they are not specifically asked for in the questionnaire. Such information might give helpful information about your individual reaction to the illness, and thus help us prescribe the best medication for your problem.
Of particular importance are changes that you have noticed recently, in appetite, in desire or aversion for particular foods, in behaviours, sleep patterns, bowel habits, dreams etc., so please report any such details that you have noticed.
Request for Consultation
Contact Number - Landline Code Number
Contact Number - Mobile Code Number
Please write a brief account of your present problems and information about how long you have had them (in chronological order). Please describe fully the trouble, including its origin, subsequent development and effects of treatments that were received. In this description, please be certain to cover at least the following points:
Area of body affected and when
Sensations and pains experienced
Circumstances (physical & emotional that have brought on the trouble)
Conditions that increase the trouble
Conditions that reduce the trouble
All other accompanying troubles
Your Habits How Much?
Milestones of Life
(As far as you can recollect): teething, trying to sit up, walking, talking, etc. (whether on time, delayed, early).
History of Trauma
Broken bones, Accidents, Head injuries, Dog/Insect bites, etc.
Past / Childhood History
Diseases suffered Approximate age Duration Whether you completely recovered Medicines & treatment taken Any other particulars
Going all the way back to paternal and maternal grandparents. (Any history of Allergies, Arthritis, Asthma, Cancer, Diabetes, Epilepsy, Hypertension, Kidney diseases, Liver diseases, Skin diseases, Stroke, Tuberculosis etc.) etc.
Appetite & Thirst
How is your appetite?
How is your liquid intake?
(Feel thirsty all the time, fairly normal etc.)
Any change of taste in your mouth?
What are the foods or drinks you like? Is there a tendency to indulge in particular kinds of foods, like for example,
sweets, sour foods, salty foods, etc.
What are the foods or drinks which make you worse? Are you allergic or sensitive to any foods?
How is your bowel habit?
(Regular, constipated, diarrhoea etc.)
Do you have belching or passing of gas?
Is it modified by anxiety? By diet (e.g. spicy food causes diarrhoea)?
Urination & Urine
Any problems regarding urination or urine?
Do you sweat at all? If yes, how much do you sweat?
Where do you sweat noticeably? (Scalp, upper lip, under arms, back, chest, etc.)
Do you perspire on the palms or soles?
Any symptom relating to sweating? Under what circumstances?
(While eating, under tension, when you physically exert yourself etc.)
Cold / Cough
Do you catch cold easily?
Any problems relating to sex or sexual organs
What kind of weather are you most comfortable in? (Summer, humid weather, winter)
Are you particularly uncomfortable in any weather or climate?
How is your tongue â€“ clean or coated?
What about tonsils, adenoids and polyps in nose?
What about salivation?
How is the quality of your sleep most of the time? (Rested and refreshed, feel tired most mornings etc.)
Do you dream at all? If you do, do you remember them? What is the content, like for example, daily events, falling into space, running after a train, etc.?
In general, do you like being out in the open air or do you feel more comfortable in closed rooms?
How would you describe yourself? (Amiable, a loner, quite social, very picky or particular about things like cleanliness and keeping appointments, things to be done in a certain way or at a particular time etc.)
How do you react to stress and tension? (Tend to be verbally expressive, tend to keep things to yourself and brood about them, etc.)
Additional Information if any
Additional Queries for Female Patients
Age at onset of periods (Menarche)?
Periods? (Regular / Irregular) Yes No
Physical symptoms preceding the onset of periods (E.g. heaviness/pain in the breasts, changes in moods, changes in appetite, changes in bowel habit, backache, pain in the legs, headaches, dreams etc.)
Duration and interval between periods (e.g. bleeding lasts for 3-5 days and the interval between periods is 27 days)
Are you using any contraceptive pills? Yes No
Any discharge before/during/after periods? Before During After
Number of children and whether the deliveries were normal?
Any post-delivery problems?
Were the children breastfed or not?
Any problems during the breastfeeding phase?
Any complications after abortions?
Age of onset of menopause
Did the periods cease gradually or abruptly? Gradually Abruptly
Have you had any operations done in the pelvic area? Yes No (if yes details)