Details of Suffering/Disease

Present Complains (Write in your own words)
Past History (Give in sequential order with treatment taken)
History of injury/accident
About your Family & Hereditary
Father	Mother
Occupation	Occupation
Disease (if any)	Disease (if any)
Brother's & Sister's
No. of Brothers	No. of Sisters
Disease (if any)	Disease (if any)
Any major disease in Maternal/Paternal side
Married at age of
About your Spouse
Occupation	Disease (if any)
Children
No. of Son	Disease (if any)
No. of Daughter	Disease (if any)
You as individual stages of life
Your Birth Normal Premature Caesarean
Your childhood (education & major events)
Adolescence / Puberty	Adulthood
Present life
Different changes in nature of occupation
Your financial status at different stage of life
History of any failure / disappointments, grief, reverse of fortune, loss of money, ambitions, fright (specify)
History of vaccinations and any health problem related to Vaccination
Your mind, intellect, will, emotion & consciousness
Your own observation about mind	Your memory Active Normal Forgetful Weak
Observation of other about your mind
If forgetfulness then specify for what
Your anger Easily angered Trifles Violent Mild Suppressed Silent Grief	If other please specify
Your reaction in anger (eg. throwing things, striking yourself , leaving meals, weeping, suicidal)
Your fear of what (eg: ghosts, snakes, high places, dark, alone etc.)
Your anxiety (of what) and since when
Weeping and effect of consolation	Easily Trifles Cannot weep
Religious affection	Normal Too much occupied Want of religious feeling
Spending of money	Avarice Generous Extravagant Normal
Liking for Music and type	More Indifferent Hate Music Normal
Liking for Nature	More Too much occupied Want of religious feeling
Habits	Behavior (eg. Biting nails)
Narcotics Yes No	Alcohol Yes No Excess Sometimes
Tobacco Yes No Excess Sometimes
Colors you like most	Colors you don't like
Social likings Like Alone Better in Alone Like company of few Like large crowd	Delusion (if any)
Consolation Likes Dislikes Irritated No effect	Nature Aggressive Submissive Withdraw Dominative Dictatorial
Thoughts Burned in thoughts Absorbed Absent minded	Talking Too much talkative Silent Talking in sleep Normal
Fastidious (particular about) Appearance about Dress about Time about	If others specify
Physical
Vertigo	Pain
Head	Hair
Dandruff / Lice	Eye (during sleep) Closed Open Partially Open
Ear	Face
Nose	Mouth (during sleep) Closed Open Partially Open
Salivation	Growth
Teeth	Pain
Caries	Throat
External Throat	Stomach
Appetite	Food liking
Dislike	Abdomen
Pain	Digestion
Flatulence	Stool Color
Rectum	Pain
Growth	Chest
Heart	Back (region)
Extremities	Sleep
Position	Covers Likes Dislikes Must
Dream Casual Repetition
Perspiration
Parts of body	Staining
Odor	Bath Like Dislike
Bath with Cold water Warm water	Air Open Likes Dislikes Feels better Worse Closed Draft
Weather (feels better in)	Weather (feels worse in)
Season
Liking	Dislike
Sex (Male)
Desire Increased Decreased	Any abnormality
Sex (Female)
Menses Interval	Duration
Color	Pain or associated trouble
Other discharges	Other abnormalities
Medical treatment taken Yes No	Diagnosis made earlier Yes No
Diet routine & food taken
Besides these questions you can answer following questions in detail	or any other thing which you want to share with us.
1. General Symptoms
Q. 1 - At what time in the 24 hours do you feel worst?
Q. 2 - In which season do you feel less well?
Q. 3 - How do you stand the cold, hot, dry, and wet weather?
Q. 4 - How does fog affect you?
Q. 5 - What do you feel when exposed to the sun?
Q. 6 - How does change of weather affect you?
Q. 7 - What about snow?
Q. 8 - What kind of climate is objectionable to you, and where would you choose to spend your vacation?
Q. 9 - How do you feel before, during and after a storm?
Q. 10 - What are you reactions to north wind, south wind, to the wind in general?
Q. 11 - What about draughts of air and changes of temperature?
Q. 12 - What about warmth in general, warmth of the bed, of the room, of the stove?
Q. 13 - How do you react to extremes of temperature?
Q. 14 - What difference do you make in your clothing in winter?
Q. 15 - What about taking colds in winter and in other seasons?
Q. 16 - How do you keep your window at night?
Q. 17 - What position do you like best sitting, standing, lying?
Q. 18 - How do you feel standing a while, or kneeling in church? What sports do you engage in? What about riding in cars or sailing? How do you feel before, during, and after meals?
Q. 19 - What about your appetite, how do you feel if you go without a meal?
Q. 20 - What quantity and what do you drink? What about thirst?
Q. 21 - What are the foods that make you sick, and why?
Q. 22 - Like : sweets, salty things, sour, greasy food, eggs, meat, pork, bread, butter, vegetables, cabbages, onions, fruits?
Q. 23 - What about wine, beer, coffee, tea, milk, vinegar?
Q. 24 - How much do you smoke in a day, and how do you feel after smoking?
Q. 25 - Are the drugs to which you are very sensitive or which make you sick?
Q. 25 - What are the vaccinations you have had, and the results from them?
Q. 27 - What about cold or warm baths, sea baths?
Q. 28 - How do you feel at the seaside, or on high mountains?
Q. 29 - How do collars, belts, and tight clothing affect you?
Q. 30 - How long are your wounds in healing, how long in bleeding?
Q. 31 - n what circumstances have you felt like fainting?
2. Mental symptoms
Q. 32 - What are the greatest grief's that you have gone through in your life?
Q. 33 - What are the greatest joys you have had in life?
Q. 34 - At what time in the 24 hours do you feel blue, depressed, sad, and pessimistic?
Q. 35 - How do you stand worries?
Q. 36 - On what occasions do you weep?
Q. 37 - What effect does consolation have on you?
Q. 38 - On what occasions do you feel despair?
Q. 39 - In what circumstances have you ever felt jealous?
Q. 40 - When and on what occasions do you feel frightened or anxious?
Like, some people are afraid of the night, of darkness, to be alone, of robbers, of certain animals, of death, of certain diseases, of ghosts, to lose their reason, of noises at night, of poverty, of storm, of water.
Q. 41 - How do you feel in a room full of people, at church, at a lecture?
Q. 42 - Do you go red or white when you are angry, and how do you feel afterwards?
Q. 43 - How do you stand waiting?
Q. 44 - How rapidly do you walk, eat, talk, write?
Q. 45 - What have been the complaints or effects following chagrin, grief, disappointed love, vexation, mortification, indignation, bad news, fright?
In time of depression, how do you look at death?
Q. 46 - Tell me about over-consciousness and over-scrupulousness, about trifles; some people do not care about too many details and too much order.
3. Food cravings and aversions
Of course, all these questions have been already asked in the beginning of the questionnaire, but by asking you again, you are able, by doing some cross-questioning, to determine if they have been answered well the first time or not.
Q. 47 - What is the kind of food for which you have a marked craving or aversion, or what are those that make you sick or you cannot eat?
Q. 48 - What about pastry and sweets?
Q. 49 - What about sour or spiced food?
Q. 50 - What about rich or greasy food?
Q. 51 - How much salt to you need for your taste?
Q. 52 - What about thirst and what do you drink? Coffee wine, beer, etc.
4. Sleep
Q. 53 - In which position do you sleep, and since when that position? Where do you put your arms, and how do you like to have your head?
Q. 54 - What are you doing during sleep?
Like some people speak, laugh, shriek, weep, are restless, are afraid, grind their teeth, have their mouth or their eyes open.
Q. 55 - At what time do you wake up, or when are you sleepy? What makes you restless or sleepy?
Q. 56 - What about dreams?