| What are present complaints and what is their duration? (Write in decreasing order of duration )
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| How do you get relief in your complaints or how your complaints get worse?
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Whether your troubles increases or decreases by following factors ( + for increase, - for decrease)
1. Time- morning,evening,noon,night,11AM, 4PM to 9 PM),after midnight
2.Seasons
3.Heat
4.Cold 5.Sleep
6.Walking
7.Standing
8.Sitting
9.Lying
10.Weakness
11.Motion
12.Rest
13.Sea side
14.Pressure
15.Touch
16.Travelling
17.Exertion
18.Periodicity
19.Open air 20.Close room
21.Warm bed
22.Change of weather
23.Cloudy
24.Wind and Storm 25.Eating
26.Dry weather
27.Wet weather
28.Sun / Moon
29.Bath & washing
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| (In Case Of Pain) |
| What is the location of the pain?
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| What is the duration oof the pain or periodicity?
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| What is the causation of the pain?
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| Whether the pain is fixed / migration in nature?
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| Is there any associated complaint with the pain,mention it?
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| How do you get relief in pain or how it get worse?(change of wheather, lying,
eating,touch,sleep,time,temperature,season ,bathing,from motion or rest,from heat or
cold or due to any other reason)
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Other Details. |
| How is your sleep?
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| Whether you like to be in open air or indoors?
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| Whether you feel much heat in summers or much cold in winters in comparison with others?
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| What is the best sleeping position for you?
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| What particular thing you prefer or dislike to eat? (write desire/aversion in order of preference
for sour,salty,spicy,meat,fried,milk,chocolate,butter,chalk,lime,tea,coffee )
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| Do you feel trouble with above mentioned things? |
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| Which type of food and drinks do you like? |
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| Do you feel heat / burning / coldness in palms and soles ? |
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| Do your hands and feet sweat a lot ? |
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| Whether your sweat is offensive ? If yes, which type of smell it is ? |
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| Do you have a tendency to catch cold ? |
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| Appetite : Normal/Increased / Decreased /Absent |
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| How much thrist do you feel ?How many times and how much quantity of water do you take at a time ?
Thrist :Normal/Increased / Decreased /Absent/Unquenchable |
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| Whether your stools are satisfactory/ un satisfactory or requires straining ?
specify no. of motions Whether stools are hard/loose/normal in consistency ? |
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| whether you are suffering from piles/fissures or per rectal bleeding ? |
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| Do you have trouble before ,during and after micturition ? |
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| Family History (diseases regarding parents and near relatives) |
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| Do you feel any abnormal sensation in any of your body parts? (give details) |
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| What sort of dreams do you see (accidents,animals,water,drawing,falling,ghost,travelling,murder,rape, robbers,dead relatives,
dying,dead bodies,future events, religious) |
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| Whether your dreams often repeat ?(if yes which one) |
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| Do you feel frightened or get scared ? (give reason for that) |
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| Do you have any mental tension or angry ? Whether complaints started after that? |
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| whether you are suspicious ? if yes on whom ? |
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| Do you have habbit of biting nails ,sucking clothes,thumb,eating clay/lime ? |
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| Do you feel any trouble in noise,crowd, smell , 0r at sight of blood, music, light, thinking of symptoms ? |
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| What negative thoughts come to your mind frequently ? |
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| Are you irritable or gentle ? |
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| Do you get restless or anxious ? When it is maximum and how do you get relief ? |
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| Do you have any anxiety ? (future,family,children , disease, property , work , money ) |
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| Do you lack confidence or feel nervous or anxious in any special situation ? |
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| Do you feel like going home whenever you are away ? (homesickness) |
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| whether you start weeping on least troubles ? Does it relive you? |
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| Write in detail about all your delusions,illusions,hallucinations ? |
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| How is your memory ? loss memory / concentraion ? |
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| Whether you are forgetful about name , figures , persons , past events ? |
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| Do you feel heat or burning all over the body ? |
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| Do you feel better in company or alone ? Whether you try to be reserve ? |
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| How do you feel when someone consoles you during trouble ? Whether you feel better or worse ? |
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| What are feelings regarding neatness , cleanliness or work being executed in order ? |
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| whether you like to bath or wash hands and feet frequently or you have a habbit of it ? |
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| What are your feelings when you see someone in trouble ? |
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| How do you feel during logical conversation with someone ? |
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| whether you are disposed contradict others ? |
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| How do you feel when someone doesn't obey you or rather contradict you ? |
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| Whether you get easily offended or vexed or angered ? |
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| How much time you take to be normal when you get upset ? |
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| Whether you are easily carried away by lucrative talks or emotions or you rely easily on others ? |
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| Whether you are shy or timid by nature ? |
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| Do you feel sorry for anything or any work of yours ? |
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| Do you tendency to find fault in yourself or you are not satisfied with your work ? |
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| Whether you find fault or critisize others ? |
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| Whether you feel life charmless or you wish to die or commit suicide ? |
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| How do feel while talking to others ? Whether you have habit of talking to yourself ? |
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| How is your will power ? Whether you are obstinate ? |
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| Whether you have habbit of theorizing or making castles or you think too much ? |
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| do you have strong desire to achieve something or any post ? |
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| when and how do you feel angry and how do you express it ? Whether vyou loose control on yourself ? |
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| whether you break things or destroy them inn anger ? |
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| Do you feel proud of anything ? (clothes , money , intellect , beauty , any other possessions ) |
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| Are you greedy or miser ? Are you afraid of poverty or desire to earn more money ? |
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| Whether you feel like taking revenge with someone or hate anybody ? |
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| Whether you want to justify even if you are wrong ? |
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| Whether you are self respecting , egoistic , proudy , selfish ? |
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