itp

prasad please post more details following the questionnaire.

Please give as much information as you can. Never feel that you're
'talking too much'.

Sex: Age: Marital status: Children: Occupation: Habits(like
smoking/ alcohol/ tobacco, partying etc):

1) Family Medical History:

Father/Mother:

Grandparents(Maternal and paternal):

Brothers and sisters:

Spouse and children:

2) Patient's Medical History: (Include vaccination history and the
reactions to them if any)

Major illnesses(Chronologically):

Operations(if any chronologically):

Present medication:

Previous medication:

3) a) Present your Complaints in order of priority:(Give as much information as you can in your own words without much reference to medical and technical terms.)

b) Can you connect these complaints to any other events? What was going on in your life personally, physically, emotionally, socially, environmentally when the complaints came on?

c) What are the things, which aggravate your suffering and which are those, which make you feel better? Example- time, temperature, pressure, rubbing, washing, eating, tight clothing, movement, climate, music, consolation, thunderstorm, exam or other important events, smell, noise,light etc. Are you worse on any particular side of the body ?



4) Physical Profile:

Colour of hair: Colour of eyes: Skin: Complexion: Build: Posture:
Height: Weight: Nails: Other

5) Mental Profile:

a) Describe yourself in your own words:

b) Any grief, broken relationship, any anger/resentment against anybody, any fears, any phobias?

c) Do you have any strange, peculiar or unusual symptom or feelings? How are you different from others?

6) a) If Female:(Describe in detail where ever necessary)

Age of Puberty: Cycle of periods:

Please describe the irregularities in periods, like pains, moods, flow
type, clots, sensations etc if there are any?

Pregnancy problems—before/during/after delivery: Number of pregnancies:

If Menopause—headaches/flushes/sweats/dryness/mood swings/memory?

Any problem with intercourse?

b) If Male:

Any problem with intercourse or sexual organs?

7) Do you think you are able to satisfy your sexual desires in general?

8) What do you crave for in food items and in general and what are your aversions in food items and in general?

9) Describe your thirst and hunger? (Examples: Average or Excessive or
thirstless or loss of appetite or any other associated details)?

10) Describe your sleep? Do you have a particular posture of sleeping?
Are there any Recurring or significant dreams?

11) Describe about discharges (colour/odour/consistency)? [ Nasal, from ear or sweat (where do you sweat more? head/trunk/limbs etc), stool and urine.]

12) what is your preference—in climate, weather? (Examples: sun/shade/cold
dry/cold damp/hot humid/not extreme/well ventilated)

13) Other details you want to say or if there are any peculiar things going on in your physical or emotional plane.