QUESTIONNAIRE FOR PATIENTS:
Please answer this questionnaire in as great detail as possible and send it to our email for our analysis and evaluation. After the analysis we will get back to you regarding your case.
Name:
Age:
Sex:
Occupation:
Marital status:
Address*:
Email:
Phone numbers*:
Follow the instructions.
1) List out all your complaints. (Example headache, fever, diarrhoea, vomiting etc)
2) Kindly give a detailed description regarding each compliant
(some hints: i.e. what is your exact difficulty, what make you approach the doctor, what is the probable cause for the starting of the complaint ,since when is it present, is it increasing in severity or stand still or coming and going , what is the time in which your compliant is worsening or reducing, what make you give relief of the complaint , are there any associated symptoms with this complaint, is it related to the weather changes, change in diet, regarding the pain – the type of pain , where is it originating , where does it extend to . )
A) Kindly furnish details of your past illness and vaccinations (Past History)
b) Kindly furnish details if illness suffered by your father, mother, siblings, grand parents, Maternal & Paternal Aunts and uncles,
3) GENERAL INFORMATION:
(a) Give details regarding your appetite, thirst, sleep, bowels, urine, Sweat
(b) Are there any specific desires and aversions in your diet?
(e.g.: sweets, sour foods, salty foods, etc.)
(c) Are you allergic or sensitive to any foods / articles / any other things?
(d) What kind of weather are you most comfortable in? / What is your reaction or tolerance to the different types of climate? (Summers, humid weather, winter)
(e) Are you particularly uncomfortable in any weather or climate?
(f) What about your dreams?
(g) Give details about your routine activities? Your schedule of the day? Give details about your behavioural patters, reactions to situations, your inner feelings, etc
Additional Information (if any)
kindly send the scanned copies of any previous Medical reports- blood, x-ray, MRI, CT scan
ADDITIONAL QUESTIONS FOR FEMALE PATIENTS
1-Age at onset of periods (menarche)?
2-Details of menstrual Periods? (Regular/Irregular),
Dates of last menstrual periods,
3-Details regarding the flow,
Clots,
Pain,
Associated symptoms,
Any discharges,
Are you using any contraceptive pills? Yes No
Any complaint before, during or after the menses?
Details of previous Abortions / pregnancies?
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?
Age of onset of menopause?
Did the periods cease gradually or abruptly? Gradually/ Abruptly
Have you had any operations done in the pelvic area? Give details
Additional information
Children’s (age, sex):
Skin colour:
Colour of nail:
Hair (colour, falling, thin/thick, split, dry/shiny etc…):
Height:
Weight:
Pimples:
Face (oily/dry/combo):
If any other:
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