Please provide the following contact information:

First Name
Last Name
Middle Initial
Title
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
E-mail

This questionnaire should be useful to you in describing your complaints in detail. Your response will help me decide the proper line of treatment for you. In describing your complaints please be as complete as possible.  We require the following details of each of your symptoms:  NOTE Consultation charges are applicable.

I want to Consult for Skin Problem List of problem Eczema Psoriasis Lichen Planus Vitiligo Hair Loss Alopecia Baldness Urticaria Dandruff Fungal Infection Ringworm Tinea Versocolor Acne/Pimples Allergic Rash Dark Circles Sexual Problems Infertility Sexual weakness Azospermia Oligospermia Stress Anxiety Depression Sleeplessness Forgetfullness Loss of Memory Mania Acidity Constipation Piles Fissure Chronic Cold Sinusitis Asthma Allergy Backachae Arthritis Gynecological Problems Irregular menses Leucorrhoea Renal Calculi Uterine Fibroid Overweight Loss of weight Migraine Visual disturbance

CAUSE: The likely cause (s) of your present symptom.

LOCATION: The exact site, side and where the symptom spreads.

SENSATION: The type of sensation or pain, in your own words, however simple or funny it may seem.

MODALITIES: All factors that tend to either increase or decrease the intensity of your symptom.

DISCHARGE: Quantity, Consistency (thick, thin etc.), Color. Does it irritate or make the parts raw and sore? Is it blood stained?

PART 1: History of your present illness. Please describe each of your symptoms (as given above) in chronological order.

PART 2: Past history of illness. Any medical, surgical, gynecological or mental illness that you have had from childhood to date.

PART 3: Family history of illness- in parents, siblings, children, grand parents, uncles, aunts, etc.

PART 4: About yourself. Please describe the following things about yourself: appetite, food-cravings & aversions, thirst, bowel activity, urinary symptoms, sweat (where, how much, smell, stains, etc.), any abnormalities or peculiar problems in the skin, hair, mouth, teeth, gums, ears, eyes, nose, nails. Your reaction to heat and cold. Any habits or addictions? Are you thin, stocky or obese? Is your tongue coated?

PART 5: Menstrual function. Are your cycles regular? How long do they last? Is the bleeding profuse, moderate or scanty? any clots, odor, stains? What is the color of the menstrual discharge? Any symptoms associated before, during or after the menses? Do you ever get a white discharge? Can you describe it? How many pregnancies? Any problems during labor? Any miscarriages or abortions (induced)?

PART 6: Sexual problems. Any particular feelings or symptoms appear before, during or after sexual intercourse? Increased or decreased desire for sex? Any other sexual disturbance?

PART 7: Sleep & Dreams. Is anything unusual about you in sleep? Is it disturbed? Do you suffer from insomnia? Can you tolerate lack of sleep? What type of dreams do you get? Any recurrent dreams?

PART 8: Mental state. Describe freely and frankly your anxieties, fears, worries etc. Do you often become depressed? When? Do you ever become suicidal? Do you brood a lot or harbor pent up feelings? Are you irritable? Impatient or hurried? Jealous or revengeful? Do you weep easily? When? How do you react to consolation and sympathy? Are you shy, timid, reserved, introvert, extrovert, dominating, mild and yielding? What is the greatest grief or joy that you have experienced?

PART 9: Give a picture of your situation in life and your relationship with each of your family members, friends and associates.

Please contact me as soon as possible regarding this matter.