Dr.

AMIT’S SWAROOP CLINIC : QUESTIONNAIRE FOR ONLINE CONSULTATION

PLEASE PROVIDE FOLLOWING INFORMATION AND SEND IT TO: swaroopclinic@gmail.com

PRELIMINARY INFORMATION:

Name:
Date of Birth:
Postal Address:
Education:
Occupation & Designation:
Email ID:
Phone numbers:

From where did you get my reference:

CHIEF COMPLAINT:

What is your chief complaint for which you are seeking medicine?

Please state since how long do you have your problem?

What is the probable cause (physical, emotional, environmental, if any)?

What are the factors which make your problem worse or better?

What is the diagnosis made by your local physician?

What is the treatment you are taking currently for this complaint? (drugs & doses)

ASSOCIATED COMPLAINT(S):
In this section, please describe if you have any other complaints other than described above.
Describe about them in the same way as done in chief complaint.

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 Dr. AMIT’S SWAROOP CLINIC : QUESTIONNAIRE FOR ONLINE CONSULTATION

GENERAL INFORMATION ABOUT YOU:

What is your current weight?

What is your current height?

Describe your hair and skin type –

How is your overall appetite? Any change in recent past?

Do you have a strong desire for any of the following food items?
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 __

Do you have a craving for something unusual?

Raw onion__ Mud__ Threads__ Paper__

What are the food items or tastes that you do not like at all?

Are there any foods that do not suit you, or aggravate your complaints?

Thirst : How often do you drink water, and how much?

arge quantities of water __ small quantities of water __ hot drinks __ cold drinks __ room
temperature drinks __ ice cold water __

How much do you sweat? On which body parts do you sweat the most?

How are your bowel habits? Do you suffer with either constipation / diarrhea ?

Which weather suits you the most (state reasons)?

Any sexual affections?

excessive sexual appetite __ premature ejaculation __ pain during sexual activity __ problems
with orgasm __ impotence __ infertility __ vaginal dryness __ sexual dysfunction __ difficult
coition __ repulsion for sex __ sexually dissatisfied __ painful erections __

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 Dr. AMIT’S SWAROOP CLINIC : QUESTIONNAIRE FOR ONLINE CONSULTATION

Do you get affected by any of the following? (if yes, describe the consequences)
Hot humid weather / Thunderstroms / Dark cloudy weather (lack of sunlight) / Snow

Are there any addictions (if yes, state quantity per day)?
alcohol __ cigarettes/tobacco __ sex __ coffee __ chocolate __ narcotics __ illegal drugs __
sedatives __ diet pills __

LIFE HISTORY:
Major highlights of your life since early childhood, if you think are relevant to your health issues.

YOUR MENTAL MAKE-UP:

Homeopathic remedy selection is predominantly based on the study of mind, thus write about
your thoughts & feelings in an elaborative manner.

1. How would you describe your disposition or temperament? (Chose whichever suits)
Affectionate / Meticulous / Fastidious / Shy / Indifferent / Impulsive / Messy /
Generous / Anxious / Destructive / Worrisome / Obsessively Compulsive / Docile /
Dominating / Mild & Timid / Moody / Jealous / Religious or Spiritual / Intellectual /
Leader / Follower / Discouraged / Absent-minded / Friendly / Pleasing everyone /
Sensitive to hurt / Reserved

2. Areas of interests – Hobbies – Entertainment:

3. Do you have any fears ?
enclosed spaces___ failure __ affection __ contradiction ___ others opinion ___ being touched __
heights __ crowds __ snakes ___ the dark __ driving __ death __ illness __ burglars __
thunderstorms __ being alone __
4. Negative memory or incidence:
a. Has it resolved – how:
b. What pinched the most:
2. What have been the most positive memories? Your achievements so far?
3. Did you suffer with any of the following? Presently or in the past? Did you need to take
treatment for any of the emotional issues so far?
mania __ emotional instability __ hallucination __ confusion __ depression __ poor memory __ poor
concentration __ learning disability __ suicidal tendencies __ anger __ broken heart __ anxious ___

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 Dr. AMIT’S SWAROOP CLINIC : QUESTIONNAIRE FOR ONLINE CONSULTATION

repulsion for sex __ desire for attention ___ aversion to mental work __ aversion to company __
aversion to children __

4. What makes you angry:

a. Do you express it – How:
b. Can you forgive and/or forget:
c. Revenge – action / thought of:
5. How would you react to:
a. Uncleanliness:
b. Untidiness:
c. Contradiction:
d. Injustice:
e. Traffic chaos / break rules:
f. Beggar or poverty:
g. Violence – direct or indirect:
6. How often do you feel guilty, if you do any mistake:
a. How do you resolve it:
7. Do you feel you are anxious:
a. Triggering factors
b. Physical manifestations:
8. Your social nature:
a. How will you describe yourself?
Very very social (can’t stay alone even for an hour) / more social (than peers) /
averagely social / do not like to mix / loves solitude / asocial
b. Do you like social events like party / get-togethers :
c. How fast you can talk to a stranger:

Anything of your temperament that you would like to change, if possible – why:

Describe your nature at work place:

Describe your social nature:

Describe your relationship with all your family members:

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 Dr. AMIT’S SWAROOP CLINIC : QUESTIONNAIRE FOR ONLINE CONSULTATION

How is your sleep pattern? Do you feel refreshed after sleep?

normal __ deep __ disturbed __ restless __ interrupted __ short __ night terrors __ sleep walk
__ sleep apnea ___ insomnia __ bad mood on rising ___

State if you see any specific or repetitive dreams often -

Anything else about your mind, which is important for the doctor to know?

FOR FEMALE PATIENTS ONLY:

At what age did you get your first menses? Complaints experienced, if any -

How is your current menstrual cycle pattern (regular / irregular / absent / etc)?

How much is the quantity of flow (heavy / scanty / regular)?

Do you experience any changes in body and mind before menses?

Do you experience any changes in body and mind during menses?

Do you experience any changes in body and mind after menses?

Pregnancy: any complaints during pregnancy?

Mood changes after the delivery, if any ?

Complaints experienced during breast feeding, if any?

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 Dr. AMIT’S SWAROOP CLINIC : QUESTIONNAIRE FOR ONLINE CONSULTATION

Any history of abortions (with reasons)?

Menopause: age of onset, body and mood changes experienced during -

PAST HISTORY:
Write down about diseases you have suffered in past (e.g.: Skin disease, T.B., typhoid, allergy,
pneumonia, surgery, etc.) – Have you been hospitalized for any reason so far ?

INVESTIGATIONS & LAB REPORTS:

Please write about physician's findings and lab reports about your health issues.

FAMILY HISTORY:
Diseases that your family members have suffered with (Diseases similar to yours, cancer, skin
diseases, tuberculosis, diabetes, heart disease, allergy, etc.)

PAST TREATMENT:
Please write what major medications/ medicines have you taken in the past.

ANYTHING ELSE?
Any other information that you would consider useful in your case evaluation.

RECENT PHOTO:
Please email your latest photograph, since the constitutional assessment is also done through
the physical features.

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Dr. AMIT’S SWAROOP CLINIC : QUESTIONNAIRE FOR ONLINE CONSULTATION

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