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Question and Answer

 
Online Treatment
Name:*
Age:*
Sex:
Marital Status:
Address:
E-mail:*
Occupation:
Education
1. Main complaints and other associated troubles.
Where is the trouble; duration of trouble.
What exactly do you feel
What are the factors that causes this trouble
What makes it worse/better
Onset of trouble (chronologically) in detail.
Treatment method adopted and its result
Is there any trouble associated with the main complaint.
2. History of previous disease
Duration and treatment methods adopted
Vaccination history
3. Family History
No. of siblings
History of diseases in family
Causes of death and age of death
4. Pers. History
About childhood
Academic performance
Nature of work
Place of work
Any major incidents in life and the effect of it on life
Nature of interpersonal relationships
Marriage and offsprings
Habits/Addiction:

Smoking Snuff Alcohol
Sleeping pills Laxative
5.
Appetite
Thirst
6. Cravings (likes)/Aversions (dislikes)/Disagrees

Alcohol Bread Butter Bitter Salt Sweet Sour Fats Milk
Mud Chalk Egg Spicy food Meat Fish Fruits Fried Food
Warm food-drink Cold food-drink Ice Ice cream Chocolates
Tea Coffee
Anything else:
7. Bowel movements:
Nature of stool, frequency, satisfactory or not.
Any discomforts associated with defecation
Urine:
Frequency, nature, volume
Any discomfort before, during or after urination/odour
8. Sexual Sphere: (General)
Desire for sex
Frequency
Any symptom appearing before or after sexual intercourse
Masturbation-
Frequency
Homo Hetro sexual
For men:
Any difference in erection/want of erection/weak erection/Ejaculation early/late
Any other trouble in sex.
For Females:
Menses: Age of 1st Menses
Regular
 No ( Early Late)
Duration of menses
Interval between two periods
Nature of flow
Blood colour
Consistency
Odour
Staining No
If staining, can it be washed off easily Yes No
Pregnancy:
Number, Nature of delivery, Discomforts during pregnancy.
Any miscarriages (at which month)
Discomforts before/during/after menses
Is there any discharge-
Nature/color/consistency/odor/itching/ when and what makes it worse/better.
Menopause:
Age/discomforts associated with it.
Breast:
Any trouble, pain/discharge, swelling
Do you pass any gas from vagina.
Do you feel internal parts pushing from vagina.
9. Sleep
The quality of sleep, the quietness or restlessness of sleep, position of sleep, times of waking and reasons for waking, need for cover over various parts of the body, whether the window must be open or closed etc. common dreams, somnambulism, peculiar sounds or gestures during sleep, etc.
10. Sweat
How much, what parts, staining, Odour
11. Weather
Tolerance to temperature, humidity, weather changes, sun, foggy weather, wind drafts, closed rooms, etc.

12. Mental Status
Describe about yourself
The quality of the patient's life in relationship to loved ones, family, friends and colleagues. Overall quality of energy available to function in daily life, and under various circumstances.
Any mental/emotional shocks occurring in the patient's life-grief, major financial losses separation from loved ones, death, identity crisis and other stress in life.
Memory,ability to concentrate/comprehend
Are you fearful of anything eg: Animals, people, being alone, darkness, death, disease, robbers, thunder, storm, high places.
Are you anxious about anything: if yes, give details
Are you impatient
Are you doubtful or suspicious
Are you hurt easily (emotionally)how do you react. Does it cause hatred/revenge.
Does your pride get hurt easily.
Are you depressed, if so, reason/circumstances.
Do you like to share your problems.
Effect of consolation
Do you ever become suicidal when? How
Memory- quality if poor, for what ( eg. Names, places, people, what you read)
Do you weep easily, effect of weeping, ie, does it make you worse or better
Are you easily irritated. What makes you angry, how do you express it
Are you destructive
 
How good are you in making decisions.
Do you like company or like to remain alone.
How seriously are you affected by disorder and uncleanness in your surroundings.
How does failure appear to you?
Are there any matters that you deeply dislike?
What activities you deeply like? How does it affect your mood?
Are you affectionate? How does others sorrow affect you?
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