Name
Last Name
Age
Sex
Gender
Male
Female
City
Phone
Email
Street Address
State / Province / Region
Select A Country
Afghanistan
Albania
Algeria
Andorra *+
Angola *+
Antigua and
Barbuda *+
Argentina *+
Armenia *+
Australia *+
Austria *+
Azerbaijan *+
Bahamas
Bahrain *+
Bangladesh *+
Barbados *+
Belarus *+
Belgium *+
Belize *+
Benin *+
Bhutan +
Bolivia *+
Bosnia and
Herzegovina *+
Botswana *+
Brazil *+
Brunei *+
Bulgaria *+
Burkina Faso *+
Burma *+
Burundi *+
Cabo Verde *+
Cambodia *+
Cameroon *+
Canada *+
Central
African Republic *+
Chad *+
Chile *+
China *+ (see note 3)
Colombia *+
Comoros *+
Congo (Brazzaville) *+
(see note 4)
Congo (Kinshasa) *+
(see note 4)
Costa Rica *+
Côte d'Ivoire *+
Croatia *+
Cuba *!+
Cyprus *+
Czech Republic *+
Denmark *+
Djibouti *+
Dominica *+
Dominican Republic *+
Ecuador *+
Egypt *+
El Salvador *+
Equatorial Guinea *+
Eritrea *+
Estonia *+
Ethiopia *+
Fiji *+
Finland *+
France *+
Gabon *+
Gambia
Georgia *+
Germany *+
Ghana *+
Greece *+
Grenada *+
Guatemala *+
Guinea *+
Guinea-Bissau *+
Guyana *+
Haiti *+
Holy See *
Honduras *+
Hungary *+
Iceland *+
India *+
Indonesia *+
Iran +
Iraq *+
Ireland *+
Israel *+
Italy *+
Jamaica *+
Japan *+
Jordan *+
Kazakhstan *+
Kenya *+
Kiribati *+
Korea
Korea
Kosovo *
Kuwait *+
Kyrgyzstan *+
Laos *+
Latvia *+
Lebanon *+
Lesotho *+
Liberia *+
Libya *+
Liechtenstein *+
Lithuania *+
Luxembourg *+
Macedonia *+
Madagascar *+
Malawi *+
Malaysia *+
Maldives *+
Mali *+
Malta *+
Marshall Islands *+
Mauritania *+
Mauritius *+
Mexico *+
Micronesia
Federated States of *+
Moldova *+
Monaco *+
Mongolia *+
Montenegro *+
Morocco *+
Mozambique *+
Namibia *+
Nauru *+
Nepal *+
Netherlands *+
New Zealand *+
Nicaragua *+
Niger *+
Nigeria *+
Norway *+
Oman *+
Pakistan *+
Palau *+
Panama *+
Papua New Guinea *+
Paraguay *+
Peru *+
Philippines *+
Poland *+
Portugal *+
Qatar *+
Romania *+
Russia *+
Rwanda *+
Saint Kitts and Nevis *+
Saint Lucia *+
Saint Vincent and
the Grenadines *+
Samoa *+
San Marino *+
Sao Tome and Principe *+
Saudi Arabia *+
Senegal *+
Serbia *+
Seychelles *+
Sierra Leone *+
Singapore *+
Slovakia *+
Slovenia *+
Solomon Islands *+
Somalia *+
South Africa *+
South Sudan *+
Spain *+
Sri Lanka *+
Sudan *+
Suriname *+
Swaziland *+
Sweden *+
Switzerland *+
Syria *+
Tajikistan *+
Tanzania *+
Thailand *+
Timor-Leste *+
Togo *+
Tonga *+
Trinidad and Tobago *+
Tunisia *+
Turkey *+
Turkmenistan *+
Tuvalu *+
Uganda *+
Ukraine *+
United Arab Emirates *+
United Kingdom *+
United States +
Uruguay *+
Uzbekistan *+
Vanuatu *+
Venezuela *+
Vietnam *+
Yemen *+
Zambia *+
Zimbabwe *+
Address
QUESTIONNAIRE
1. Is your suffering increased ?
morning
Afternoon
Before Midnight
After midnight
Early morning
2. Is your suffering increased ?
Summer
Winter
Rainy
3. Is your suffering increased by eating any particular food substance
Sour
Sweet
Pungent
Spicy
Cold
Hot
4. Is your suffering increased by
Lying Down
Sitting
Standing
Walking
Bending
5. Is your suffering better by ?
Fanning
Air Conditioner(a/c)
Warmth
Cold Application
Warm Application
6. Is it better by
Eating
Delayed eating
7. Is you suffering increased by
Drinking water
Not drinking water
Drinking water occasionally
Drinking Frequently
8. Bowel movement?
Constipated
Tendency for Diarrhea after outside food
Diarrhea due to any specific type of food
Pass stool immediately after eating anything
9. Is there Bleeding while/after passing stool?
Yes
No
10. If Yes for the above question, then is the stool
Hard stool
Soft stool
11. Is there any Pain
While passing stool
After passing stool
12. Is there any protruding mass from the anal region?
Yes
No
13. Do you suffer from burning micturition/urination?
Yes
No
14. If YES for the above question, how often?
Days
Weeks
Months
15. Is it because you drink less water?
Yes
No
16. Is it because of illicit intercourse?
Yes
No
17. Do you get pain in the sides of the abdomen?
Yes
No
18. Is your pain in the abdomen related to urinary symptoms?
Yes
No
19. If YES for the above question, then mention about it in the box provided
20. How is your flow of urine?
Normal
Dribbling
Thin
Intermittent
21. Have you been diagnosed by any specialist about your urinary problem?
Yes
No
22. If YES for the above question, then mention about it in the box provided
23. Select the appropriate box regarding your Menstrual cycle / Menses ?
Regular
Early
Late
Very Late
Profuse
Scanty
Prolonged
Pain associated with Menses
24. Is your suffering
Better after menses?
Aggravated after menses?
25. Do you feel the need to mention any other symptoms?
26. Is your suffering
Painful
Better after drinking water
Better after eating?
Worse after
Select
sour food
spicy food
oily food
Better after menses?
27. Is your suffering
Localised
Extending (radiating)
28. Is your suffering
Better
Worse
Select
a.Rest
b.Movement
c.Pressure
29. Area of suffering
Confined to Right
Confined to Left
Whole
30. your suffering associated with ?
Nausea
Vertigo (Giddiness)
Any other - Mention
31. Do you get pain in the sides of the abdomen?
Yes
No
32. Is YES for the above question, when is it more?
Morning
Evening
Night
Midnight
Early Morning
33. Do you feel better after Fanning (or) A/C?
Yes
No
34. What will give you relief?
Lying down
Sitting
Standing
Moving
With Inhaler?
35. When is your noseblock increased?
Day
Night
36. Do you have sneezings?
yes
No
37. If YES for the above question, when is it more?
Morning
Night
Midnight
Early morning
38. Is Nose block associated with heaviness of head?
yes
No
39. If YES for the above question, then when is it more?
yes
No
40. Do you feel better by?
Warm drinks (water)
Cold drinks (water)
41. Is there any discharge from the nose?
yes
No
42. If YES for the above question, then what is the consistency?
Thick
Watery
Greenish
Yellowish
Offensive (smelly)
43. Describe your skin type ?
Dry
Oily
Scaly
Patchy
Depigmented Patches
Anything else you need to mention
44. Do you get rash on your skin?
yes
No
45. If YES for the above question, when does it occur?
Morning
Evening
Night
46. Is there itching?
Yes
No
47. If YES for the above question, when is it more?
Morning
Night
Midnight
Early Morning
48. Is it increased by any specific cause?
Food
Weather change
Dust
Allopathic Drugs (Conventional Medicine drugs)
49. Is your skin condition associated with any other clinical condition?
Yes
Select
a.Cough
b.Bronchial Asthma
c.Nasal Catarrh
No
50. Is your weight slowly increasing?
Yes
No
51. If YES for the above question, is it due to ?
Overeating
Sedentary Lifestyle
Heridity (Family)
Allopathic Medicines
Thyroid problems
52. Is there unwanted hair on your face?
Yes
No
53. Is your menses / menstrual cycle disturbed in relation to above question?
Yes
No
LAB INVESTIGATIONS- Attach your previous reports
ANY SPECIAL INFORMATION- If there is any special info. you want to share with us pertaining to health, please be clear (specify). That may help us to select a correct remedy. There should not be any inhibitions. You may also inform us if you have any specific craving/ specific aversion/ specific modalities i.e., if you are aggravated/relieved by any particular activity. You can also mention any specific incident/ disease/ or accident or anything that happened before developing this disease.
This information is also very useful for choosing a right remedy for you