Adul

tPat
ientQuest
ionnai
re

Inhomoeopat hi
ctreat
ment ,
hist
oryofthepati
enti
s
extr
emelyi mport
ant.I
ttakesaboutonehourormoret
o
analyzeacase.
Wet akeintoconsi
derati
onbothphysicalaswel
lasment
al
aspects
ofthepatient
.

Asitisnowuniv
ersall
yacknowledged,ourmindhasa
tr
emendousinfl
uenceonourbody .Forgivi
ngproper
tr
eatment,
iti
sabsolutel
ynecessarytounderst
andthe
pati
ent’
semoti
onalandintel
lect
ualnature/
behavi
or.

Inordertogetabet terinsi
ght,thepati
entwil
lhaveto
answert hequest i
onnai rehonestl
y,car
eful
lyand
completely.Thisinformat i
onwi l
lhelpustounderst
andt
he
pati
ent,his/herreactionstosituati
onsandhelpusin
prescr
ibi
nghim/herthecor
rectr
emedyandav
eryposi
ti
ve
approachtowar
dslif
e.

Werequestt
hepati
entnottohesi
tat
e,i
ntr
ospect
andwri
tedowneveryt
hingi
ndetai
l.

I
nst
ruct
ions
•Pat
ientsshoul
dwr i
tet
heanswersbelowsothatwe
canpreser
vetheinf
ormati
onforf
utureref
erence.
•I
fyoufal
lshortofspace,pleasef
eelfr
eet
oat
tach
anA4sheetwit
ht hequesti
onnumber .

Al
ltheinfor
mationgivenbythepat
ientwi
llbe
maint
ainedincompletesecr
ecy.
1.Pr
eli
minar
yInf
ormat
ions

Name–Vi
nodhS
Address- 2ndwestst
#524, r
eet,
KamarajNagar
,
Thi
ruvanmiy
ur,
Chennai-
600041,Tami
lnadu
Cont
actNumber–09884206050
E-
mai
l–Vi
nodhshekhar
92@gmai
l
.com
Dat
eofbi
rt
h–27/
07/
1992
Pl
aceofbi
rt
h–Chennai
Ti
meofbi
rt
h–5:
50am

2.Chi
efCompl
aint
s(pr
esent
lyper
soni
ssuf
fer
ingf
rom)

Describeev er
ysy mptom indet ail
:Racingmind, Alway
s
thi
nkingaboutr andom things.Fel l
i
ngv erystr
essedand
i
rrit
ated.Idream everyni
ght .Vaguel yam abl
etor emember
thedreams.Her edreamsar enotni ght
mareorbad
dreams, butj
ustrandom t hingswhi chIthi
nkaboutduring
theday .Thisl
eavesmef eel unrestedwhenIwakeupand
feeli
rri
tatedtheentir
eday .
Onsetanddur
ati
on:
Thi
shasbeenhappeni
ngf
ort
hepast
2-
3y ear
s.
Chr
onol
ogyofsy
mpt
oms–Howdi
ditf
ir
stbegi
n,pr
ogr
ess
et
c.:
Ireal
lydon’tr
ememberbecauseIv
ebeenf
aci
ngt
his
pr
obl
em foralongtime.
Diagnosi
s,i
fanymadebyphysici
an/
speci
ali
st.
:Cur
rent
ly
undergoi
nghomeopat
hict
reatment.
Treatmenttakenfort
hedisease.
:No.
2Passif
lor
a,SBL
Sleepti
ght(
fi
nished1bot
tl
e), Kal
i
um Phophor
ica6x
(Current
lyt
aking)
Factorsthati
ncr
easeordecreasethei
ntensi
tyofi
l
lness.
(Aggravati
ngandAmmeliorati
ngfact
ors)
:

3.Associ
atedCompl
aint
s

Anyothercomplai
ntst
hepati
entexper
iencesal
ongwi
th
chi
efcomplai
nts,onandoff
.:Nothi
ng

4.PastHi
stor
y

Anymaj
ori
l
lness
Acci
dents/injur
ies:Under
wentsur
ger
ytwi
cef
ort
orn
meniscus(
Rightknee)

5.Fami
l
yHi
stor
y
Histor
yofdi
seaseoranymajori
l
lnessi
nthef
ami
l
y:
Fatherdi
edofcancer(
Gast
ri
c)

6.Gener
alI
nfor
mat
ion

Appet
it
e
Poor/Av
erage/Heal
thy:
Heal
thy
St
rongl
i
kes/di
sli
kesf
orf
oods:
-
Tendencyt
oindul
gei
ncer
tai
nfoods:
-
Foodal
l
ergi
es(
ifany
)–pr
awns

Temper
atur
e
Mor
etol
erantt
o-Col
d/Hot:
Col
d
Weat
hermostcomf
ort
abl
ein?Col
d
Weat
hert
hatmakesy
ouuncomf
ort
abl
e?Hotandsweat
Per
spi
rat
ion
Doy
ouper
spi
repr
ofusel
y?Yes/No
I
fyes,
wher
eandunderwhatnot
cir
cumst
ances?Not
much
I
sthei
rof
fensi
vesmel
l/st
ainst
hecl
oth.No
Sl
eep
Qual
i
tyofsl
eep-Poor
Youwakeup-Ref
reshed/Fat
igued-Fat
igued
Sl
eepi
ngPosit
ion-si
dewi
se,
abdomi
nal
,st
rai
ghtsupi
ne.:
St
rai
ghtsupi
ne

Dr
eams
Doy
oudr
eam?Yes/No:
Ever
yni
ght!
Doy
our
emembery
ourdr
eams?Yes/No:
Par
ti
all
yyes.
Whatdoy
oudr
eam about
?Random t
hings
Doyouhav erecur
ri
ngdreams?Yes/NoI fyes,descr
ibe.
:No.Butduri
ngdayalsoIloosemysel
fthi
nkingabout
somethi
ng.

Bowel
s
Fr
equency-Regul
ar/I
rr
egul
ar:
Regul
ar
Stool–Regular/Const
ipat
ed/Loose:
Par
ti
all
y
regul
ar/
loose
Ur
inenor
mal
?Yes/No:
Yes

Thi
rst
Li
qui
dint
ake–(
Low/Av
erage/Good)Av
erage
Howof
tendoy
ouf
eel
thi
rst
y?Notmuch

SensesandSensi
ti
vi
ty
Sun,
Noi
se,
Odour
s,Weat
herchanges
Phy
sical
Sesi
ti
vi
ty:
tightcl
othi
ngar
ound
Per
sonal
det
ail
s
Wei
ght:
75
Bodyst
ruct
ure(
Lean/Av
erage/Fl
abby
)Av
erage
Hei
ght(
Tal
l/shor
t):
6ft

Li
fest
yle
Addi
ctions/habit
s?Play
inggamesoncomputer
.Kindof
addi
ctedbutnottotheextr
emeIlooseot
herwor
ks.It
’sa
bi
gtimepassf orme.
Doy ouexer
cise?Yes/No: Ver
ymuch.Iwasobese(
87
kgsbefore1y ear
).Idi
dlot
sofcar
dioandl
ostar
ound15
kgs).
Doy oul
i
keyourj
ob?Yes/No:
Ivebeenwor
kingf
ort
he
past1mont
handIlikei
t.
Recr
eat
ional
act
ivi
ti
es
Sexl
i
fe
Socialli
fe:Soci
all
yact
ive.Nohesi
tat
ionsi
nany
rel
ationshi
ps.
Spi
ri
tual
li
fe:
Athei
st.Ihav
etogodbel
i
ef.
7.Per
sonal
Hist
oryoft
hepat
ient

Chi
l
dhood
Chi
ldhooddi
seases:
Jaundi
ce(
age9),
lept
ospi
rosi
s(age
7)
Yourhappiest
/mostpainful
childhoodmemories.
:Ihada
roughti
medur ng8th-
i 12thst
dasIl ostmybrot
her(diedi
na
bikeacci
dent)andl
ostmyf ather(Cancer
).
Yourchi
ldhoodnat
ure(t
imid,Shy
,hy
per
act
ive,
mischi
evous,r
ebel
l
ious,
etc.)
:Nor
mal
Basi
cnat
ureandbehav
iori
nchi
l
dhood.
Har
mlessandf
ri
endl
y

Fami
l
y
Yourrel
ati
onshi
pwit
hindiv
idual
familymember
s-I
fany
probl
emswi t
hanyofthem,expl
ain.
Anyi
nsecur
it
ies,
disappoi
ntment
sorot
heri
ssueswi
th
fami
l
ymember s?
Posi
ti
oni
nsi
bli
nghi
erar
chy
.Andr
elat
ionshi
pwi
tht
hem.

Sel
f
Pat
ient
scl
earpi
ctur
eofhi
s/hersi
tuat
ioni
nli
feandhow
her
eactt
othesi
tuat
ion.
Doyougetanxi
ous(
nervous/depressed)
?Relatedto
whatandhowdoyoureacttoi
t?Igetdepressedbutnot
ner
vous.
Haveyousuffer
edanyser i
ousshock/gr i
ef/
di
sappoi
ntment/f r
ight/mentalagony?Ifyesdescr
ibei
n
det
ail
:WhenIl ostmybr ot
herandfather,Iwasnotvery
emoti
onalbackthen.Butatthepresentam abitemoti
onal
per
son.
Areyouworri
edorunhappyov eranypersonal/domest i
c/
fi
nanci
al/socialoranyotherr
elatedmatt
er?Ifyes,
descr
ibei
ndet ai
l
.Iam veryheathconsci
ousper son.Iam
waytoconcernedaboutmyheal thandthepresent
probl
em makesmef eel
i
ngwor r
ied.
Yourambi t
iony ouhav e/
hadinli
fe?Whatdi
ffi
cult
iesar
e
youfacing/
hav ealreadyfacedi
nachiev
ingit
?Want edto
becomeapi l
ot.Butduet odeat
hofmyf at
herIcouldn
makeit.NowIf i
nishedmyengineeri
ngandwor ki
ngas
superv
isor.
Yourgreat
estgr
iefy
ouhav
ehadi
nyourl
i
fe?Ment
ioned
above
Yourgr
eat
estj
oys/happi
nessy
ouhav
ehadi
nyourl
i
fe?
Act
ivi
ti
est
haty
oul
i
ke/di
sli
ke.
Movi
es/books/dr
amas/personsthathasi
nfl
uenced
yout
hemostandwhy?Idon’
tgeti
nfl
uenced.
Whatdoy
oul
i
keabouty
ourj
ob?Ver
year
lyt
otel
l
Anyunwantedthought
s,any
time?Expl
ain:
Unwant
ed
thought
saboutmyheath.
Onwhatmat
ter
sdoy
ougeti
mpat
ient
?Food
Whatareyouproudof?Doesyourpri
degeteasi
lyhur
t?I
n
whatway?Yesmypr i
degetseasi
lyhurt.Iam v
ery
sensi
ti
vei
nthisarea.
Whatsuper
ior
it
y/i
nfer
ior
it
ycompl
exdoy
ouhav
e?Not
hing.
Howseri
ousl
ydoy ougetaff
ectedbydisor
der/
uncl
eanl
i
nessinandaroundyoursur
roundi
ngs?Il
i
ket
o
havemysurr
oundi
ngsclean
Howi
syourmemor
y?Lat
elyi
tsv
erybad
Whatmakesy ouangry
?Howdoy ouexpressyouranger
?
Whatbodilysy
mptomsdoy oudevel
opwhenangr y(
e.g.
tr
embling,
sweati
ng,et
c.)?Argui
ngmakesmev er
yangry.I
expr
essmyangerbygoi ngpassiveandsi
lent
.Nobodily
symptoms
Howdoy
our
eactt
ocont
radi
cti
on?Ipar
ti
all
yaccept
/agr
ee.
Howlongdoyour
ememberwheny
ouar
ehur
tbyot
her
s?I
easi
l
yforgi
ve.
Doy
ousuppr
essy
ourf
eel
i
ngs?Whenandwhy
?
Doy ouweepeasil
y?Whatmakesyouweepandhowdo
youfeelaf
terweepi
ng?
idon’
tweepeasi
lybutwhenIdoI
feel
bett
er.
Howdoyoufeeli
fsomeoneof f
ersyou
sy
mpathy/
consol
ati
on?Idon’tl
ikepeopl
eshowi
ng
sy
mpathyonme.Consolat
ionisfine
Areyoudoubtf
ul/suspi
ciousbynat
ure?Ofwhat
?Ki
ndof
doubtf
ul/
suspi
ciousinnatur
e.
Howr
evengef
ular
eyou?Notatal
l
.
Anysui
cidal
tendenci
es?Yes/No:
NO
I
fy es,
when?Inwhatmannerdoyoucontemplat
e
toendy ourl
i
fe?Whatpr
event
edfrom doi
ngso?
Eventhenareyouaf
rai
dofdeath?
I
ny ouropini
onwhichaspectofy
ourmi
ndandmoodsar
e
notagreeabl
etoyou?
Maj
orev
ent
sthathav
eimpact
edy
ouadv
ersel
y?
Howdoesf
utur
elookt
oyou?Noi
dea.
Doy ougetal
ongwellwit
hf ami
ly/col
l
eagues?I
fnot
descri
beprobl
ems.Igetalongwell
.
Schoolandcol
l
egeenv
ironment(
fort
eenager
s)Nor
mal
andsocial
.
Arey ouanxi
ous/upset/nervous/depressedaboutany
mat t
erinyourf
ami l
y/school/coll
ege/fri
ends?(f
or
teenagers):
Anxious,upset,
depressedaboutmyown
l
ife
Doyoufeelt
hatyourfami
lymember s/parents/f
riends
don’
tunder
standyou?Ify
es,expl
ain(f
orteenager
s)
Ar
ey oubei
ngdomi natedbyyourpar
ent
s?I
fyes,
forwhat
?
Pl
easeexpl
ain.(
forteenager
s)
Anyotheri
ssueswhichy
oufeeli
mportantenoughtowri
te
aboutyour
sel
f,whi
chhassofarnotbeenment i
onedi
n
thi
squesti
onnai
re?
No.
7.Addi
ti
onal
Inf
ormat
ion(
forwomen)
Ageofonsetofper
iods?
Regul
ari
tyofper
iods?
Phy
sical
sympt
omspr
ecedi
ngonsetofper
iods?
Dur
ati
onofper
iods?
I
nter
val
bet
weenper
iods?
Whatmet
hodofcont
racept
ivedoy
ouuse?
Di
schar
gebef
ore/dur
ing/af
terper
iods?
Numberofchi
l
dren?
Ty
peofdel
i
ver
y?
Postdel
i
ver
ypr
obl
ems?
Pr
obl
emswi
thbr
east
feedi
ng?
Anyabor
ti
onsandcompl
i
cat
ions?
Ageofonsetofmenopause?
Di
dyourper
iodsceaseabr
upt
lyorgr
adual
l
y?
Sur
ger
yorot
herpr
obl
emswi
thr
epr
oduct
ivesy
stem?