Questionnaire

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Questionnaire

Please fill in this questionnaire in as great detail as possible.

Name *

Age *

Your Email *

Address

Please write a brief account of your present problems and information about how long you have had them (in chronological order).

Family History : Going all the way back to paternal and maternal grandparents. (Allergies, skin problems, asthma, Alzheimer's, migraines, any other neurological disorders, heart problems, cancers, mental disorders, etc. For example, " Elder sister has/had eczema, paternal aunt died because of complications of heart disorders, maternal grandma had Alzheimer's," etc.

Childhood History:(As far as you can remember) whether your delivery was normal or caesarian, whether there is a history of neonatal jaundice, measles, mumps, typhoid etc. Any effects of vaccinations like fevers, loose bowels, frequency of colds, running nose, coughs.

History of broken bones, accidents, head injuries, dog/insect bites etc.

General Information:

(a) How is your appetite?

(b) Is there a tendency to indulge in particular kinds of foods (eg: sweets, sour foods, salty foods, etc.)

(c)What kind of weather are you most comfortable in?(Summers, humid weather, winter)

(d)Are you particularly uncomfortable in any weather or climate?

(e) Do you sweat at all? If you do, where do you sweat noticeably? (Scalp, upper lip, under arms, back, chest, etc.) Under what circumstances?(While eating, under tension, when you physically exert yourself etc.)

(f) In general do you like being out in the open air or do you feel more comfortable in closed rooms?

(g)How is the quality of your sleep most of the time? (Rested and refreshed, feel tired most mornings etc.)

(h) How is your bowel habit? (Regular, constipated, diarrhea etc.) Is it modified by anxiety? By diet (eg. spicy food causes diarrhea)?

(i)How is your liquid intake? (Feel thirsty all the time, fairly normal etc.)

(j) How would you describe yourself? (Amiable, a loner, quite social, a tendency to be very picky about things like cleanliness and keeping appointments etc.)

(k)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 Questions For Female Patients:

Age at onset of periods?

Periods? (Regular/Irregular)

Regular

Irregular

Clear selection

Physical symptoms preceding the onset of periods (eg: 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 (eg: bleeding last for 3-5 days and the interval between periods is 27 days)?

Are you using any contraceptive pills?

Yes

Clear selection

Any discharge before/during/after periods?

Before

During

After

Clear selection

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 abortions? Any complications after abortions?

Age of onset of menopause?

Did the periods cease gradually or abruptly?

Gradually

Abruptly

Clear selection

Have you had any operations done in the pelvic area?

Yes

Clear selection

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms