PsoriaTreat: Understanding Psoriasis, Delivering Solutions.

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Psoriasis specialist doctor in India
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#38+ Years of Expertise

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.

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2) On what parts of your body you have psoriasis?
3) In what season your psoriasis is aggravated?
4) In what season your psoriasis is ameliorated?
5) Did any of your blood relative have or had psoriasis?
6) Did you suffer from any major illness before?
7) What are the major illnesses in your Father, Mother, brother, and sister?
8) Have you been vaccinated for following diseases?
9) Did any animal or insect bite you before?
10) Are you addicted to any drugs?
11) Did you have any grief, sorrow, vexation or emotional setback prior to psoriasis?
12) What are the treatments you have taken earlier and their result?
13) Does your wound heal in time or not, does it suppurate easily?
14) What food items you crave for?
15) What food items you hate to eat?
16) Do you crave for salt, Clay, Chalk, etc?
17) What food items you can not tolerate or cause any trouble to you?
18) How is your thirst?
19) How much do you sweat?
20) Does your sweat have any odor?
21) Does your sweat leave any stain on your cloths, White, Yellow, Black etc....?
22) How is your appetite? Normal, Less, More e.g. If you can not tolerate hunger or you are hungry at midnight?
23) Do you have any digestion problem, Eructation, Flatulence, Acidity etc...?
24) How are you motions (stool)?
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?
29) Do you need fan or air condition usually?
30) Do you need light or heavy covering in bed at night?
31) How do you sleep?
32) Do you sleep immediately after going to bed or it takes much time to sleep?
33) (a) Do you wake at night frequently or not?
33) (b) Do you wake by least noise?
34) (a) Do you get dreams?
34) (b) Any specific dream you always see?
35) (a) Describe your disposition?
35) (b) Are calm or hot tempered?
35) (c) Do you easily get anger?
35) (d) Can you control your anger?
35) (e) What do you do when angry?
36) Do like company or enjoy being alone?
37) Do you easily get nervous?
38) How do you react to contradiction?
39) How is your confidence?
40) Do you weep easily or not?
41) Do you share your problems with other or keep it with you only?
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?
45) Is it painful?
46) How is the quantity, scant, normal, and profuse?
47) (a) Do you have leucorrhoea problem?
47) (b) Describe in relation to occurrence?
47) (c) Quantity, its relation to monthly cycle?
48) How many children you have? How was their birth, normal, difficult, forceps delivery, caesarian etc

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Erandwane, Pune, Maharashtra 411004

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