Questionnaire for Taking the case.
Date :
Name :
Age :
Sex : Male Female
Occupation :
Address :
Mobile No :
Email Id :
Marital Status : MarriedUnMarried
Height : TallMediumShort
Build : ThinNormalObese
Present (Cheif) Complaints :
Part of the body affected :
Sensations and complaints :
Modalities. Aggravation / Amelioration :
Probable Cause :
Any disoder of sense of taste/Smell/Hearing/Vision/Touch :

Physical Generals :

Appetite / Hunger :
Is it normalExcessiveDeficientCapricious(At usual time)
Does he feel filled up after morsels of food Yes No
Abdomen Bloated Yes No
Flatulence(Gas) Yes No
Heatburn Yes No
Eructation Yes No
Thirst :
Thirsty (Drinks a lot in a day) Yes No
Thirsty Less (Drinks comparatively little in a day) Yes No
Quantity and frequency : Thirst For Large Small
Intervals Long Short
Piles :
Bleeding Blind Protruding Itching
Burning Fissures Painful Fistula
Aggravated by
Ameliorated
Craving, Aversion, Disagree :
(Please mark C/A/D in the box according to your condition)
Sweet Salty things Sour things Milk
Eggs Meat / Fish Butter Spices
Potato/starchy food Fried things
Raw Vegetables Onion/Garlic Juicy, refreshing things
Alcoholic liquors ANY OTHER
Drinks- WarmColdIce cold
Stools :
Normal Constipated Loose Dysenteric

Nature of Stools :
Soft Hard Bloody Slimy With urging Must strain
No of Stools :
Sleep :
Normal Sound Disturbed Difficult
Too sleepy Sleeplessness Unrefreshing
Position in sleep :
Back On right Left lies on abdomen Head rise
Dreams :
Pleasent Unpleasent
Side of the body Affected :

(Please name the anatomical region, also,stating right or left side of the body)

Complaints first appeared in Right Left
Complaints then extended to Right Left form
Complaints shift from place to another Yes No
Cold or hot(Burning) Sensation :
Cold Hot
Vertex Eyes Ears Face
Stomach Abdomen Back Palm
Soles Any other
Sweat : If excessive
Where :
When :
Odor of sweat :
Does it stain clothes :
Color of the stain :
Very little sweat (dry skin) :
Partial sweat on :
Head Face Soles Others
Skin :
Eczema Psoriasis Dermatitis
Atopic Dry Wet
Nature of disease
Dry Oozing Itching
Moist Watery Viscid Bloody
Pus Burning
Urine :
Profuse / Scanty
Frequent Dribbling Burning InvoluntaryDayNight
Colour : Yellow Brown Bloody Milky
Odour : Pungent Offensive Ammonia
Painful Urination : Before During After
Deposits : Albumin Pus Epith-cells
Sugar : Present Nil
Stones : Ca-oxalate Urates
Postion in which urine passes easily : Bending Sitting Standing
Modalities :
At which time the complaint is aggravated / ameliorated :
Under what circumstances the complaint is aggravated / ameliorated :
In what season the complaint is aggravated / amelioration :
Breathing :
Any Complaints :
Bronchitis :
Asthma Rapid Oppressed Rattling
Wheezing Difficult Expiration Inspiration
Cough :
Hollow Harassing Tickling Spasmodic
Dry Loose
Sexual
Male :
Desire Strong Weak NIL
Erection Strong Weak
Emission In sleep During stool/too early
Coition, any complaint during, or after:
History of venereal diseases:
Female :
Age at first menstruation :
Menses : Profuse / Scanty
Too early Too late Normal
Flow :
Red Dark Pitch like Smell Fetid Any other
Nature of the complaint in relation to menses :
Leucorrhoea :
Watery Thick Tenacious Smell Fetid Acrid
Excoriating Anyother
Cause Itching :
Abortion if any :
During which month of pregnancy :
Coition : AversionDesire
Strong Weak
Before Menses During Menses After Menses
Number of children :
Normal Delivery Caesarean Sterility
Mental Attitude
Sensations
Ball Plug Burning Heat Benumbing Bruished Bursting Splitting Chilly Cramps
Constricting Contracting Dizziness vertigo Emptiness fullness Itching Internally Tingling Lethary
Scratching Hammering Neuralgic Numbness Restlessness Scraping Sinking Feeling Jerking Twitching
Stiffness Rigidity Stinging Sprained Dislocated Throbbing Pulsating Trembling Quivering Tightness
Tension Any other
Other Complaints if any