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QUESTIONNAIRE FOR THOSE WHO WISH TO CONTACT THROUGH E-MAIL. First of all it is made very clear that utmost regard is given to the privacy of the client.So,the questionnaire can be filled without any reservations as each and every word shall count significantly towards the selection of the remedy. 1.NAME:------- 2.AGE------ 3.SEX----- 4 .PROFESSION…….. 5.BRIEF DESCRIPTION OF THE PROBLEM. 5a HOW DO YOU COPE WITH THE DISEASE i.e. WHAT THE DISEASE FORCES YOU TO DO? 6.ANY MEDICINE TAKEN OR NOT. 7.DO YOU EVER THINK ABOUT YOUR DISEASE OR NOT? IF YES WHAT IS THE THOUGHT PROCESS. 8.WRITE ABOUT YOUR NATURE IN GENERAL. 9. ANY CHANGE IN MOODS DURING THE SICKNESS PL.EXPLAIN. 10.WHAT MAKES YOU ANGRY AND WHAT DO YOU DO DURING THE PERIOD ANGER STAYS WITH YOU. 11.ANY REPENTENCE AFTER GETTING ANGRY. IF YES HOW MUCH TIME AFTER GETTING ANGRY YOU FEEL REPENTENT. 12.LIKING FOR MUSIC? 13.YOUR APPETITE, THIRST AND SLEEP. PL. EXPLAIN IN BRIEF. 14. SPEAK ABOUT YOUR BOWEL MOVEMENT.IF CONSTIPATED SINCE WHEN.IF ANY HISTORY OF PILES OR BLEEDING OR PAIN DURING OR AFTER STOOL. 15. HOW YOUR BODY REACTS TO HEAT, COLD OR WEATHER CHANGE? 16 YOUR LIKING FOR SWEETS OR SALTISH. 17.MENSTRUAL HISTORY (IN CASE OF FEMALES) 18.ANY OTHER INFORMATION OR SYMPTOM WHICH YOU FEEL IS RELEVENT AND CONNECTED WITH THE MAIN DISEASE MAY BE MENTIONED. 19. WHETHER PREGNANT OR NOT 20. PROBLEMS, IF ANY, DURING PREVIOUS PRAGNANCY 21. ANY RELATIONSHIP PROBLEM THAT YOU FEEL IS/WAS WEIGHING HEAVILY ON YOUR MIND 22. ANY ANGERY OR BITTER FEELINGS TOWARDS ANY RELATION (NAME THE RELATIONSHIP WITH THE PRESON WHO YOU FEEL IS THE SOURCE OF DISCOMFORT.) 23. INCASE OF PROBLEMS OF CHILDREN, MOTHERS PLEASE WRITE WHAT WAS YOUR MENTAL STATE DURING THE PERIOD OF PREGNANCY 24. WAS THE DELIVERY: Ř C- SECTION Ř FORCEPS Ř PRE-MATURE OR OTHERWISE 25. PLEASE WRITE ABOUT YOUR NEGATIVE EMOTIONS, IF ANY, AS THEY WILL HELP IN THE SELECTION OF THE CORRECT HOEOPATHIC REMEDY FOR YOU We accept Interac, Visa & Mastercard. Please ask for charges. |
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