Questionnaire to answer if you really want proper treatmentTry to answer as many questions as possible.Some may be irrelavent to you.Just skip them.
1.What is the main reason you need treatment?
2.Describe your complaints giving the following details:
a. What does it feel like?
b. When does it happen?
c. What sort of things make it worse?
d. What sort of things make it better?
e. What else was happening when it first appeared?
f. Describe the quality of the pain, being as creative as you can. How would someone else imagine the pain happening to them?
g. What does it look like?
h. Do any other symptoms occur immediately before, during or after?
3. What illnesses have you had in the past?
4. What illnessess run in the family?
5. What do people die from in the family?
6. What medication are you on?
7. What foods do you crave, whether you allow yourself to eat them or not? List from the strongest craving to the weakest.
8. What foods do you have an aversion to? (hatred or repulsion for)
9. What is your level of thirst, and what do you prefer to drink?
10. What foods aggravate you? (including allergies)
11. Do you suffer from any digestive complaints? What is your bowel habit like?
12. What is your level of energy like? Rate it from 1-10 (10 being excellent). How does your energy fluctuate throughout the day (and night)?
13. What is your level of sexual energy like?
14. How is your sleep? What position do you prefer to sleep in? Is there any position you cannot sleep in? Any unusual behaviour during sleep?
15. Have you had any reoccurring dreams or images/ pictures/ themes that repeat themselves in your dreams? Please describe.
16. Describe your menses (periods). Describe any PMS. Have you been through menopause? Any gynecological problems?
17. How does the weather affect you? Are you sensitive to the temperature in any way?
18. Is there anything else in the environment you are sensitive to, perhaps more so than the people around you?
19. What is the worst thing that has ever happened to you? Describe in detail.
20. What part of your life do you have the most difficulty coping with? Why is that?
21. What was your childhood like? Describe your parents and your relationship with them. Describe your relationship with your siblings and other extended family members. Did anything in your childhood have a profound effect on you?
22. Describe the romantic relationship you are currently in. What causes the most problems between you?
23. What is your occupation? What differentiates you from the other people in your place of employment? What difficulties do you have at work?
24. What is your self-confidence like? When is your confidence at its worst?
25. What fears do you have? Do you have any phobias? What things in life do you have trouble facing?
26. What parts of yourself or your life would you change if it were at all possible?
27. What do you do to relax?
28. What is something that you have told nobody else, or at least very few people? Why is that?
♥ gavinimurthy on 2016-07-24
Ans.2.Black pigmentation on face n neck .Pain in chest if I walk after taking food . Ans2b tightening of chest ,if continue walking then pain in chest .
Ans2c.walking n climbing the steps
Ans2e f .As if the chest has been tightened ,pain ,it travels to jaw .May be because of indigestion n gas formation travelling upward.Heart lung tests o k .
Ans3.migraine headache upto the age of 40
Ans6.For Hypertension n unstable Angina -1 Nicorandil 10 mg .2.Metroprolol tartrate50mg. 3.Isosorbide Mononitrate 60mg. 4.Amlodipine 5mg. 5.Candesartan 4mg.6.Atorvastain 10mg.7.Aspirinrpe75mg.8.lansoprazole 30mg.
Ans7.Sweets .esp.after meals .Controls myself to very small portion .Likes Indian sweets.
Ans8.Not exactly anything .I am a vegetarian n once a while take egg .
Ans9.about one litre a day .
Ans10.Can not guess.
Ans11.Yes ,burping and gas formation which travels upward ,causing uncomfortable feeling in chest .Constipation when travelling to different places .V.sensitive to street food ,can easily develop symptoms of food poisoning ie diarrhoea.
Ans12.Physical 6+,Mental 8+
Ans14.Sleeplessness, difficult to get sound sleep ,even if I go to bed late in night ie midnight . Straight or on left side.
Ans15.As such no recurring things in dreams .But most of the times mind is restless.
Ans16 .passed that age
Ans17.Sensitive .like moderate climate
Ans19.Death of my elder son .He was going to Mumbai by train for his practical
exam .of MD in Tata Hospital .No family member was with him .What happened in the train I do not know ,I got this shocking message next day in the morning .He was hale n hearty n very confident of first class results .v.brilliant child .
Ans20.As described above . That phase of life .
Ans21.I am the eldest child ,hence pampered ,More close to father before marriage n after marriage to mother .Cordial with brothers .
Ans23.Now retired after serving for 36years .as prof in English n as Principal of a postgraduate college .
Ans24.Very conifedent .
Ans25.Afraid of snakes ,even do not like to see a picture of it .Height phobia n drowning in the sea
Ans26.I enjoyed my professional life .If I could go back to that .
Ans27.Meeting friends ,Cook some favourite dish ,n above all play a tune on my harmonium,or read a romantic story .
Ans28.I think nothing of that sort
I was on hormone replacement therapy for two years in 2006 because I felt week during that period .My weight before was 39 kg n after it now is 65 kg .Height is 5.1
Thanks n expect an early reply .
Saroj44 3 years ago
Ans2.a. According to my height which is 5ft.2inch. I guess my weight should be around 60kgs which is not. Right now my weight is 77kgs & I have lot of breakouts in my cheeks & under chin area which doesn’t look good.
Ans3. Pneumonia (when I was 1.2 month old baby), Malaria (at the age of 12), Miner Jaundice which I fully recovered in a month (at the age of 29).
Ans5. Normal heart attack.
Ans6. Zincovit & Ursodeoxycholic Acid (I.P 300mg).
Ans7. Junk food, Sweet, Dairy product, coffee, chicken, egg, mutton, river fish, fruits & vegetables.
Ans8. Oysters, Deep fried.
Ans9. When I am thirsty I drink water. Per day I drink 3 litres of water.
Ans10. Cant guess.
Ans11. No I don’t have any complaints regarding digestion. Every day I have a clear bowel in the morning.
Ans12. Physical -3+, Mental- 8+ . Moderate in morning, lowest in afternoon, feel active during evening & night till I sleep.
Ans13. Don’t know as I am unmarried.
Ans14. I always get a good sleep. I usually sleep in 4 position.
Ans16. I have regular menstrual cycle.
Ans17. Yes, I am sensitive towards temperature & start to sneeze due to change in temperature from heat- cold or cold to hear. I even get red rashes, itchiness & burning sensation while workouts (when my body heat increases) or in contact with hot temperature.
Ans18. I am allergic to dust & pollution.
Ans19. I failed & repeated 6 standard again. Those two years where nightmare of my life. I had to suffer from bullies, teachers where not cooperating they assumed I am hopeless, couldn’t tell my parents as I already upset them with the results so I didn’t want them to be more upset. I went through mental & sexual harassment of my maths teacher. No one was friend to me.
Ans20. As mentioned above.
Ans21. They (my parents & younger sister ) are very understanding, loving, caring & sporting. My childhood was amazing.
Ans22. I do have crushes but not any romantic relationship, so don’t know much about it.
Ans24. About being confident I can say it’s not that good but not as well, actually it depends on the situation.
Ans25. I have fear of dinosaur , spider. I trouble facing failures, trust.
Ans 26. I want to look good, healthy & active, so that I can be more outgoing & make lots of good friends.
Ans27. Meditation, fashion sketching, listening music, dancing & watch kdrama.
Ans28.About being sexually harassed which I already mentioned in ans 19.
Veronica2 last year
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