Patient Form (New) - Psoriasis Treatment using Homeopathy

Patient Form

Dear Patients, we understand that below form is long to fill but it will not take more than 10 min of your time. This form is important to us and it will help us to diagnose you better so fill and submit this form completely

NOTE
Following information should be filled by the patient. Please fill up this form sincerely. Selection of homeopathic medicines is based on the answers to following questions. Wrong answers will suggest wrong remedy.
In case you do not understand a question do not answer.

* Your privacy is fully protected so fill this form without any hesitation!

Name *

Contact Number *

Email *

Age

Select your sex

Address

Religion

Occupation

1) How long you are suffering from psoriasis? (write in days, months or in years)

3) In what season your psoriasis is aggravated?

Summer
Winter
Rainy

4) In what season your psoriasis is ameliorated?

Summer
Winter
Rainy

11) Did you have any grief, sorrow, vexation or emotional setback prior to psoriasis?

13) Does your wound heal in time or not, does it suppurate easily?

16) Do you crave for salt, Clay, Chalk, etc?

18) How is your thirst?

Often
Hardly

19) How much do you sweat?

Heavy
Mild

20) Does your sweat have any odor?

Sour
Strong
Offensive
Other

21) Does your sweat leave any stain on your cloths, White, Yellow, Black etc....?

White
Yellow
Black
Other

22) How is your appetite? Normal, Less, More e.g. If you can not tolerate hunger or you are hungry at midnight?

Normal
Less
More

23) Do you have any digestion problem, Eructation, Flatulence, Acidity etc...?

25) Do you have any urinary problem?

26) Can you tolerate heat of sun? Summer?

27) Can you tolerate cold?

28) What water you prefer for bathing, cold, lukewarm, and warm?

Cold
Warm
Lukewarm

29) Do you need fan or air condition usually?

30) Do you need light or heavy covering in bed at night?

Light
Heavy

32) Do you sleep immediately after going to bed or it takes much time to sleep?

Immdediately
Much Time Required

33) (a) Do you wake at night frequently or not?

(b) Do you wake by least noise?

34) (a)Do you get dreams?

(b)Any specific dream you always see?

35) (a) Describe your disposition?

Mild
Moderate
Irritable

(b) Are calm or hot tempered?

Calm
Hot

(d) Can you control your anger?

(e) What do you do when angry?

Shout
Throw Things
Quiet

36) Do like company or enjoy being alone?

Like Company
Being Alone

37) Do you easily get nervous?

38) How do you react to contradiction?

Positively
Negatively

39) How is your confidence?

Less
Strong
Over

40) Do you weep easily or not?

41) Do you share your problems with other or keep it with you only?

Share
Don't Share

42) Do like consolation, to be helped, caressed or not?

43) Do you have any sexual problem?

44) How is your monthly cycle, regular, early, late?

Regular
Early
Late

45) Is it painful?

46) How is the quantity, scant, normal, and profuse?

Normal
Scant
Profuse
Other

47) (a)Do you have leucorrhoea problem?

(b)Describe in relation to occurrence?

Before Menses
After Menses
Always

(c)Quantity, its relation to monthly cycle?

Slight
Moderate
Copiuos

Any other thing you would like doctor to know? (write freely as it is seen by doctor only)