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Case-Taking Questionnaire

Instructions

1) Answering these questions in exquisite details is of utmost important

2) Don’t answer in mere YES or NO. Try to elaborate as much as possible.

3) Skip the section which is not relevant to you.

4) After we review this questionnaire, if we find that some more information is required from you, we may ask more questions to you

Here it goes---

Personal Details

Name:

Age:

Gender:

Email:

Weight, Height

Marital Status:

Address:

Occupation: Kindly describe if you have sitting job or traveling job

Health status: Good/Bad/Average (Elaborate if possible)

Habits: Like smoking, liquor, etc.

Present complaint:

1) What is your main/chief complaint for which you are seeking treatment?

2) Since when you have this trouble?

3) Is it increasing or static?

4) Any other medical condition you are suffering with?

Causes of illness:

(Physical, mental or emotional cause if you can make out any)

It may be typhoid fever, cold winds, unhappy childhood or sudden death of someone close.

Please try to recollect if something had happened since when you have started having this trouble

In cases of skin troubles, please mention- (You may not have it now but if you had had any type of skin problem anytime in last few years)

1) Where are/were the skin lesions?

2) Are/were they itchy?

3) Do/did they bleed on itching?

4) Any treatment for the skin trouble?

In case of pain of any type, mention—

1) How is the pain (dull, throbbing, radiating, pulsating, shooting, etc)?

2) What time of the day it is more?

3) With what the pain is aggravated or better?

4) Any associated complaint with pain?

5) Any mental symptoms/ emotional disharmony with pain?

In case of any respiratory trouble-

1) What time of the day cough is more?

2) Does it start with cold first or first cough starts and then cold?

3) Explain how does cough bother you? Does it interfere while working or sleeping at night?

4) Is there any sputum or expectoration? Does it come up easily or you have to make an effort to bring it up? What’s the colour of sputum?

5) What soothes your throat? Hot or cold?

6) Any chest pain associated with cough? Is there any pain in any other part of body due to cough?

7) Any other symptoms associated with cough?

In case of any gastric trouble, tell us-

1) Is it related to food consumption?

2) What kind of food aggravates the problem?

3) Any relation with stools?

In case of hair problems-

1) What is the exact problem? Is there alopecia? Patchy baldness or male-pattern baldness,

2) Is there a dandruff?

3) Does the scalp itch?

4) Do you sweat a lot on the head?

5) Is there graying of hair? If yes, where is graying more- front or back or sides?

In case of mind disorders-

1) Any fears?

2) Any stress?

3) What are the most recurring mind symptoms you experience?

4) What time of the day is worse?

5) How it affects your sleep?

6) Any motor disturbances?

7) Any static complaint that seems to be persistent from childhood, any childhood disharmony, vaccination history?

8) How is your sleep? Sound/alert

9) Any dreams? If yes, of what kind? Any particular dream which you often see or repeated?

10) Anything else that seems important.

Food & Appetite:

1) Any food aggravations such as feeling bloated, etc?

2) Any food cravings?

3) Any food aversions?

4) Which one you like more: salty or sugary food?

5) Do you feel unusually hungry at a particular time of the day?

6) Does eating makes you feel good or you are better on empty stomach?

7) How is your appetite?: good/bad

Thirst:

1) Do you get unduly thirsty? Or you do not feel like drinking water at all or very little?

2) How much water roughly you consume during the day and at a time?

3) Do you genuinely feel thirsty or you drink because it is healthy to drink water?

Weather:

1) Do you feel good in summers, winters or rainy season?

2) Does any weather aggravate your trouble?

Perspiration (Sweating):

1) Do you perspire more or less?

2) Any particular part where you sweat more (palms, nose brim, forehead, armpits, feet etc)?

3) Is the sweat smelly?

4) Does it stain clothes badly?

Bowel:

1) What’s the norm for you?: constipation/normal/diarrhea

2) Type of stools (ex: loose, hard) and colour of stool

3) How often you evacuate bowels in a day? Do you feel you have unsatisfactory stool?

4) Any abdominal pain during or after stool or otherwise

5) Any gaseous distension of abdomen or any symptoms related to entire gastro-intestinal tract

Urine: Any complaint or is it normal?

Back Symptoms if any- like backache, burning in the spinal region, neck pain, etc

Emotional Aspects:

(This is very crucial point for us to reach correct remedy. More details you will tell, more accurate remedy we can find for you)

1) Are you of very emotional kind or not so emotional or not at all emotional?

2) Do you cope with changing situations better?

3) Are you better in public or alone,

4) How is your temperament? Do you get irritated easily or have lots of patience?

5) Do you cry openly upon emotional disturbance or weep in solitude?

6) Do you express your emotions?

Mental Apects:

1) What’s your approach to anything new? Do you accept readily or there is resistance to change?

2) Trustworthiness and ability to make new friends?

3) Introvert or Extrovert?

Strong Family history: of similar illness or some other illness such as TB, asthma, cancer, diabetes and hypertension

Any Serious Illness: since childhood

Any surgeries and/or accidents and/or hospitalization for any purpose:

Ongoing treatment: (for this trouble or for anything else)

Photograph: Please mail us one of your latest full length photograph. This gives us better idea about the constitution of the patient. (This is a MUST)

FOR FEMALES ONLY

1) Onset of menses,

2) Whether regular or irregular?

3) Flow heavy or normal?

4) Any complaint during menses?

5) Any discharge other than menses and its colour?

6) Any problems in conception, pregnancy, delivery?

FOR CHILD ONLY

Bed Wetting Problem

1) What time of night he wets the bed most of the times?

2) Any complaints like burning urination or dribbling urine?

3) Does he wake up on wetting the bed or lies without notice?

4) Is there any nightmare sort of experience when he cries out in bed or fears due to any reason?

5) Any specific dreams related to urination like he is urinating in dreams and wets the bed?

6) Any other related complaint?

History of mother during pregnancy-

1) Any major illness during pregnancy?

2) Any history of special medication during pregnancy?

3) History of hypertension, diabetes during pregnancy?

4) Any allergies during pregnancy?

Do you want to seek just prescription or medicine also (via courier)?

What is your preferred method of payment?: Demand Draft, Online

Lastly please tell us how did you find us?

(Would be great if you can tell us the exact source)-

Thank you for your time!

___________________(Your Name)

Date:

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