Homeopathic Questionnaire


    Sex: FM


    Please answer the following questions in a descriptive manner after careful analysis and recollection of previous experiences and happenings.

    1. Describe your main suffering? ( please state exact locations, sensations, modalities, probable cause and since when):

    2. What other physical sufferings do you have in your body which are assiciated with your main suffering? ( please state all details as above):

    3. What mental sufferings / feelings do you have associated with your physical sufferings?:

    4. What exactly do you feel when you are at your worst?:

    5. When did it all start? Can you connect it to any past event affecting you mentally or physically ? Did you suffer from any other disease just before this ailment started?:

    6. Which time of the day you are worst? Is the suffering periodic?:

    7. What are the things which aggravate your suffering and which are those which ameliorate the same? ( eg. washing, cold or hot application, rubbing, pressure, physical exertion, sleeping, jar, movement etc.):

    8. Do your think your sufferings have relation to any external stimuli (like, change of place) or any internal biological changes in the body, like, menses (in females)?:

    9. When do you feel better, during hot weather or cold weather, humid or dry weather?:

    10. Describe your general mental set up? Are you Moody, Arrogant, Mild, Agreeable Changeable, Nervous, Suspicious, Easily offended, Quiet, Arguing, Irritating, Lazy etc.:

    -How do you feel before or during a thunderstorm?:

    -Do you like being consoled during your tough times?:

    -Are you sensitive to external stimuli like smell, noise, light etc?:

    -Do you have any typical habit or gesture like nail biting, causeless weeping, talking to one self etc? ?:

    -How do you feel about your friends, family, your children and especially your husband / wife?:

    11. What are your fears and do you dream of any situation repeatedly?:

    12. What do you crave in food items and what are your aversions?:

    13. How is your thirst: Less, normal or excessive?:

    14. How if your hunger: Less, normal or excessive?:

    15. Is there any kind of food which your body can’t stand?:

    16. Is your sweat normal or less or more? Where does it sweat more: Head, trunk or limbs?:

    17. How is your bowel movement and stool type?:

    18. How well do you sleep? Do you have a particular posture of sleeping?:

    19. Do you think you are able to satisfy your sexual desires in general?:

    20. What peculiar or strange sensation do you have in any part of your body at times? Is any expected symptom absent in you? Do the symptoms have any peculiarity in their onset, location, extension, periodicity and relief?:

    21. What medications have been taken earlier by you to treat this or any other diseases and what have been the results after the medication?:

    22. What major diseases are running in your family? ( any ulcers, alchoholism, suicides etc.):

    23. Describe, how do you look like? Describe your overall appearance.:

    24. (ONLY FOR FEMALES) If you are not having normal menstrual cycles, please answer the following questions:
    -Are the periods early, regular or late in general? How long do they last?:

    Do you suffer from any kind of physical or mental discomfort before, during or after the periods?:

    -Is the flow scanty, normal or excessive?:

    -Is the blood thick bright red or pale watery?:

    -Do you notice any clots in the flow?:

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