Questionnaire - Slightly revisedHi
Please find below a slightly revised questionnaire. The basis remains Rishimba's questionnaire - I have made a few changes here and there to reflect the mentals and the generals more clearly.
Patient ID: Sex: Age:
Please answer the following questions in a descriptive manner after careful analysis and recollection of previous experiences and happenings.
1. What brings you to the forum? Describe all your problems, including those that may not exactly be on the top of your mind now, in as much detail a possible.
2. How do these problems affect you mentally? How does it affect your family life and inter-personal relations with friends and colleagues?
3. What time of the day your problems trouble you the most? Describe the time modalities properly for all your problems.
4. Normally, when you are in a healthy state, what time of the day you are most active and what time you feel lazy and tired?
5. Generally, is there some time in the day when you feel extremely irritable?
6. When did it all start? Can you connect it to any past event or disease? Give proper details.
7. What are the things which aggravate your suffering and which are those which ameliorate the same?
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. Which weather worsens your complaints – wet, hot or cold?
10. Which weather do you generally prefer the most?
11. Describe yourself as a person in as much detail as possible. Discuss general personality traits; the way you express yourself in social settings, family and work environment, with friends, etc.
12. Describe in detail if you harbour any negative emotions.
13. How is your memory?
14. Do you suffer from bouts of anger? If yes, which category do they fall in – frequent, occasional or rarely?
15. Which of the following words describe you the best – Moody, Arrogant, Mild, Agreeable, Changeable, Nervous, Suspicious, Easily offended, Quiet, Arguing, Irritating, Irritable, Lazy, Super-active, Tearful, Vindictive, Confused, etc.
16. Please answer the following clearly:
- Do you tend to weep easily?
- How is your memory?
- How do you feel before or during a thunderstorm?
- Do you like being consoled during your tough times?
- How sensitive you are 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?
17. What are your chief fears?
18. How well do you sleep? Do you have a particular posture of sleeping?
19. Is there any pattern in your dreams?
20. What all food items do you crave for what all you simply hate to have?
21. How is your thirst: Less, Normal or Excessive?
22. How if your hunger: Less, Normal or Excessive?
23. Is there any kind of food which your body can’t stand?
24. Is there any time or occasion when you feel an uncontrollable urge to eat?
25. How would you rank your sweat as– normal or less or more? Where does it sweat more: Head, Trunk or Limbs?
26. How is your bowel movement and stool type?
27. Do you think you are able to satisfy your sexual desires in general?
28. How do you think you are different from others, if at all?
29. What medications have been taken earlier by you to treat the diseases and do you have any particular symptom surfacing after the medication?
30. Any major diseases running in your family?
31. Describe your overall appearance
32. (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?
Niel Madhavan on 2009-08-31
thats a better one to catch the mentals ( if the patient is able to comprehend and address all points )
To catch just the mentals and get a hang of the constitution, I have a questionnaire, which you might have seen me using in some threads.
I am pasting it below; it would be great if the essence of this one is also included in your revised questionnaire.
1. Describe your main sufferings and other related or unrelated sufferings with exact sensations, locations, modalities and probable causes.
2. Write an essay on yourself, your personality, nature, likes and dislikes, thermal preferences, cravings and aversions, fears and dreams, your ambition in life, your inner-most desires, your place in society etc.
3. What is your profession? Do you enjoy yourself at work? Is it a profession you have willingly chosen? If not, what would it be as per your choice?
4. What would you like to change in your personality, if at all?
5. Please pick out the adjectives which best describe your personality;
Nervous, Anxious, Shy, Worrying, Paranoid, Proud, Asocial, Guilty, Depressed, Hypochondriac, Untidy, Weepy, Emotional, Impractical, Confused, Suspicious, Jealous, Timid, Aggressive, Headstrong, Forgetful, Follower, Insecure, Immature, Impulsive, Rigid, Restless, Feminine.
6. Did you have any bereavement in life? If yes, how has it affected you?
7. Do you often suffer from depression? If so, do you prefer company or solitude during those times?
8. Do you get angry often? If not, do you feel the anger inside at least? What are the things / issues on which you get angry the most?
9. Do you have any issues regarding your parenting by your guardians? How were their nature / behavior towards you during your childhood and adolescents? How has it affected your personality and thoughts?
10. Would you say your sex drive is high, low or average? Do you think you are able to satisfy your sexual desires?
♥ rishimba 8 years ago
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