Questionnaire for Case-taking

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Name:
Date of birth:
Gender:
Weight:
Height:
Marital Status:

Do you have any children? If yes, how many?

Family medical history:

Past history of health:

Have you been hospitalized? If yes, when and for what condition?

Have you taken medications in the past? If so, which medications have you taken? What was your response to the medication?

Have you been vaccinated? If so, what vaccines have you received?

Do you have any allergies?

List the number of dental fillings / type of fillings / and other procedures you have had.

General Symptoms

Are you presently taking medications? If so, which medications are you taking?

Chief complaint?
When did it first occur?
What's your symptom?
Describe the sensation experienced.
Give the precise location.
List any concomitant symptoms.

Modalities

When do your symptoms get worse?
morning / evening / night / during sleep / on rising / before a thunderstorm / after a thunderstorm / in damp weather / in cold weather / wearing tight clothes / in a warm room / while washing oneself / in bed / while moving around / during rest / in a closed room / in crowded places / in the winter / in the summer / in the spring / in the autumn / at the sea / in the sunlight / lying on ones back / lying on affected side / while exercising / while talking / when the temperature changes / at the smell of tobacco / on missing a meal / on the onset of a menstruation / in cold, wet weather / in bed /

When do your symptoms get better?
bend backwards / doubled over / upon moving / resting /with cold applications / warm applications / in the morning / in the evening / in the night / listening to music / applying pressure / uncovering the feet in bed / during the summer/ at the sea / outdoors / opening a window / left alone / while eating / on the onset of a menstruation /

How's your appetite?
good / decreased / never hungry/ always hungry / capricious eater/ can't finish a meal / hungry soon after a meal /

List any eating disorder

What do you have an aversion to?
food / water/ meat / bread/ fish/ shellfish / butter/ eggs / fruits/ milk/ onions / pickles / wine /vegetables / cabbage / beans / pork / potato / soup / ice cream / cold food / warm food / sour food / sweets /

What or who do you dislike?
a family member / husband / wife / strangers / company / friends / music / noise / sun/ light / odors / exercise / being indoor / closed windows / tight clothes / being contradicted / being consoled / mental work / writing / being wrong / bathing /

What do you have a strong desire for?
alcohol / coffee / milk / bread / butter/ cheese/ meat / eggs / chocolate / lemon/ pickles / potato / sweet foods / ice cream / cheese / pastry / salty food / fatty food / sour food / bitter food / fish / oysters / beer/ wine / tea / pop / fruits / vegetables / hot foods / spicy foods / cold foods / room temperature foods /

What do you thirst for?
large quantities of water / small quantities of water / hot drinks / cold drinks / room temperature drinks / ice cold water / coffee /

What do you have an addiction to?
alcohol / cigarettes/tobacco / sex / coffee / chocolate / narcotics / illegal drugs / sedatives / diet pills /

Emotional Symptoms
mania / emotional instability / hallucination / confusion / depression / poor memory / poor concentration / learning disability / suicidal tendencies / anger / broken heart / anxious / repulsion for sex / desire for attention / aversion to mental work / aversion to company / aversion to children /

What do you fear most?
enclosed spaces/ failure / affection / contradiction / others opinion / being touched / heights / crowds / snakes / the dark / driving / death / illness / burglars / thunderstorms / being alone /

How would you describe your sleep?
normal / deep / disturbed / restless / interrupted / short / night terrors / sleep walk / sleep apnea / insomnia / bad mood on rising / avoid sleeping on the right side of the bed / avoid sleeping on the left side of the bed /

Do you have a recurring dream?
Describe your dream:

Sexual symptoms:
excessive sexual appetite / premature ejaculation / pain during sexual activity / problems with orgasm / impotence / infertility / vaginal dryness / sexual dysfunction / difficult coition / replusion for sex / sexually dissatisfied / painful erections /

Physical Symptoms

What's your body shape?
normal / slender / chubby / overweight / underweight / tall stature / short stature / medium stature / thin arms / flabby upper arms / thin legs / flabby thighs / broad shoulders / wide hips / narrow shoulders / narrow hips/ flat abdomen / big butt / hourglass shaped body / pear shaped body /

What's your face shape?
oval / square / round / heart shape / diamond shape / high forehead / receding chin / square jaw / big cheeks /

What's the colour of your skin?
white / pink / olive / brown /

What's your facial expression?
happy / sad / fierce/ cold / tired / angry / suspicious / smiling / proud / frightened

What condition is your skin?
healthy looking / unhealthy looking / dry / oily / combination / acne / flushed/ shallow/ liver spots / freckled / porcelain skin / goose flesh skin / rashes / discoloration / excessive sweating / dirty looking / moles / itchy/ bruises / warts / hives / cysts / boils / skin infections /

What is your natural hair colour?
blond / red / black / brown / grey /salt and pepper

Describe your scalp condition:
dry / oily / bald patches / dandruff / hair loss

What colour are your eyes?
blue / green / hazel / brown / dark brown

Eye symptoms:
dry / itchy / burning / discharges / pain / watery / sunken / contracted pupils / strabismus / blurred vision / diplopia / myopia / tunnel vision / photophobia / swollen lids / long eye lashes / dark circles under the eyes / tears / styes / sensitive / redness /

Ear symptoms:
impaired hearing / eruption behind ear / itching in / noises in / fluids in / inflammation in / discharge from ears / recurring ear infection / pain left / pain right / pain behind / ulceration in front of ear / ringing in the ears / hearing loss /

Nose symptoms:
long / crocked / cold tip / red tip / brown saddle on the bridge / dry nostrils / discharge right nostril / discharge left nostril / epitaxis / stuffed nose / dry catarrh / congestion of blood / obstruction of the airways/ polyps / sensitive to odors / ulcers / difficulty breathing / loss of smell / sinus infection / post-nasal drip /

Mouth symptoms:
dry mouth / drooling / bad breath / oral thrash / canker sore / excessive salivation / discoloration of the tongue / protruding tongue / ulcer / bitter taste / speech difficulty /

Lips symptoms:
dry / cracked / chapped / swollen / herpes

Teeth symptoms:
asymmetric / long / short / rectangular / loose / sensitive / grinding / numerous caries / missing teeth / bleeding gum / gum abscess / pain chewing / pain drinking something cold / black teeth / green teeth / yellow teeth /

Internal throat symptoms:
dry / inflamed / sore / sensation of a lump / excessive mucus / narrow sensation / choking sensation / swallowing difficulty / pain swallowing / hoarseness / loss of voice / throat infection /

External throat symptoms:
induration of glands / lump in the throat / goitre / pain of the thyroid gland

Respiratory symptoms:
wheezing / accelerated breathing / difficult breathing / deep breathing / asthmatic / shortness of breath / obstructed respiration / weak respiration / gasping for air / irregular respiration / slow respiration / loud / rattling / whistling / asphyxia / frequent respiratory infections / bloody sputum / yellow catarrh / persistent cough /

Digestive symptoms:
cramps / bloated / heartburn / feeling of emptiness / fullness / heaviness / indigestion after a meal / cutting pain / gnawing pain / rumbling / colic / flatulence / stomach ulcer / hiatal hernia / anorexia / bulimia /

Cardiovascular symptoms:
heart palpitations / fluttering sensation / constriction of the heart / dilation of the heart / chest pain

Stools
regular / frequent / hard / large / scanty / soft / dry / watery / bloody stools / loose / copious / greasy / frothy / bilious / fetid / odorless / colic before a stool / an urge without success / slimy mucous in stool / involuntary stool / painful stool / diarrhea / constipation /

Shape of stool
s shape / flat / narrow / chopped / pasty / balls like sheep dung

Colour of stool
brown / green / grey / black / yellow / white / ash / bluish / orange

Bladder symptoms:
weak / painful / obstructed / calculi / infection / retention of urine / sensation of fullness / paralysis

Urological symptoms:
frequent urination / albuminous / acrid / alkaline / bloody / burning / increased / scanty / involuntary / urging / dribbling / interrupted / retarded / bloody urine / painful urination / urine comes out in drops / cloudy / greyish / saffron colour / watery / prostate problems /

Arthritic Pain:

Where do you feel the pain?
hand / finger / wrist / shoulder / thumb / hip / leg / calf / ankle / foot / toes

Where do you feel stiff? shoulder / hand / finger / hip / knee / ankle

Where do you get swollen? hand / wrist / fingers / knees / legs / ankles / toes

Eczema & Psoriasis:

Where do you have eczema?
face / behind the ear / inside the ear / neck / finger / hand / arm / leg / foot / genitals / anus

Where do you have psoriasis?
in the elbow crease / in the knee crease / behind the elbow / on the knee

Where do you have dry itchy skin?
hands / feet / knees / elbows / scalp / face

Describe your menses:
early / late / normal / irregular / scant / heavy / painful / long duration / short duration / dysmenorrhea / metorrhagia / blood clots / get headaches during menstruation /

What's your disposition?
sweet / affectionate / shy / meticulous / indifferent / impulsive / loquacious / jealous / happy / messy / cheerful / capricious / absent-minded / quarrelsome / anxious / destructive / easily offended / generous / people pleaser / a bully / argumentative / the life of the party / quick to do things / vain / slow learner / violent / ambitious / obsessed with religion / verbally abusive / compulsive / an outdoor person / angry when consoled / afraid of the dentist / impatient / philosophical / afraid to die / leader / paradoxical / lover of animals / singer / moved to tears from music / rude / relieved by crying / hyper / sad / silly / discouraged / dissatisfied / serious / domineering / fastidious / dictatorial / passive / thirstless / sensitive to noise / worse in the heat / worse in dry weather