Final Questionnaire

PLEASE READ THIS BEFORE FILLING THIS FORM

Congratulations! You are almost done booking your treatment at Dr. Singhal Homeo. We are here to select the right and the most effective medicine possible for you. In order to do that, we depend on your co-operation. Homeopathic medicines are totally based on the symptoms you share with us. If we are to make a successful prescription, we must know all about your sickness. We must also consider all the features that belong to you as an individual. This includes your reactions to various factors, your past, and your mental makeup.

This information enables us to select the remedy that removes your sickness effectively.

In order to get the best idea about your health status, the symptoms, and the appropriate Homeopathic medicine, we shall be asking you a few questions. Each one of these questions has a definite meaning and is significant for us to best understand your case. There is not a single question that is useless. Even something that you think is not connected with your sickness may be the most important factor in deciding the correct homeopathic medicine. That is why you must frankly and accurately provide us with accurate information on each point. Please read each question carefully, think, and, if necessary, consult someone who is close to you and then answer completely. Please do not hide or skip anything which is asked in the points.

Don’t worry; all of your details remain absolutely confidential.

- Step 1 of 4

Date

Name *

First

Last

Date of Birth *

Age *

Weight

Sex *

Male
Female

Height

Contact Number *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Food Preference

Vegetarian
Non-Vegetarian
Eggetarian
Vegan

Education

Occupation

Problem *

Ambition in Your Life

Family History

How many brothers or sisters do you have? (Including those who died, if any)

Provide information about them in the table below. Indicate yourself by writing ‘self’.

Dead/Alive

Dead
Alive

Age

Diseases Suffered

Dead/Alive

Dead
Alive

Age

Diseases Suffered

Dead/Alive

Dead
Alive

Age

Diseases Suffered

Dead/Alive

Dead
Alive

Age

Diseases Suffered

Dead/Alive

Dead
Alive

Age

Diseases Suffered

Have your blood relatives had any of the following? If yes, please mark the box.

Mother

No Known Problems
Cancer
Obesity
Diabetes
Heart Problem
Lungs
Aids
Genetic Disorders
STDs

Father

No Known Problems
Cancer
Obesity
Diabetes
Heart Problem
Lungs
Aids
Genetic Disorders
STDs

Sister

No Known Problems
Cancer
Obesity
Diabetes
Heart Problem
Lungs
Aids
Genetic Disorders
STDs

Brother

No Known Problems
Cancer
Obesity
Diabetes
Heart Problem
Lungs
Aids
Genetic Disorders
STDs

Maternal Aunt

No Known Problems
Cancer
Obesity
Diabetes
Heart Problem
Lungs
Aids
Genetic Disorders
STDs

Maternal Uncle

No Known Problems
Cancer
Obesity
Diabetes
Heart Problem
Lungs
Aids
Genetic Disorders
STDs

Paternal Aunt

No Known Problems
Cancer
Obesity
Diabetes
Heart Problem
Lungs
Aids
Genetic Disorders
STDs

Paternal Uncle

No Known Problems
Cancer
Obesity
Diabetes
Heart Problem
Lungs
Aids
Genetic Disorders
STDs

Maternal Grandmother

No Known Problems
Cancer
Obesity
Diabetes
Heart Problem
Lungs
Aids
Genetic Disorders
STDs

Maternal Grandfather

No Known Problems
Cancer
Obesity
Diabetes
Heart Problem
Lungs
Aids
Genetic Disorders
STDs

Paternal Grandmother

No Known Problems
Cancer
Obesity
Diabetes
Heart Problem
Lungs
Aids
Genetic Disorders
STDs

Paternal Grandfather

No Known Problems
Cancer
Obesity
Diabetes
Heart Problem
Lungs
Aids
Genetic Disorders
STDs

Other

No Known Problems
Cancer
Obesity
Diabetes
Heart Problem
Lungs
Aids
Genetic Disorders
STDs

Personal History

Did your mother have any problem during pregnancy?

Did she take any drugs during pregnancy? What were they?

Was there any difficulty about your birth? Provide details:

Review of Systems:

Do you CURRENTLY have any of the following? If the answer is yes, please mark the box

General:

Weight Loss
Fatigue

Heart:

Chest Pain
Shortness of Breath

Lungs:

Chronic Cough
Coughing up Blood

Kidneys:

Blood in Urine
Painful Urination

Neurologic:

Memory Loss
Fainting

Mental Health:

Depression
Hearing Voices

Ears, Nose and Throat:

Hearing Loss
Hoarseness

Blood Problems:

Anemia
Easy Bleeding

Immune System:

Asthma
Latex Allergy

Gastrointestinal Problems

Abdominal Pain
Constipation
Heartburn
Milk Intolerance
Passing Blood with Stool
Nausea
Swallowing Difficulty
Vomiting

Past Medical History:

Have you EVER experienced any of the following? If the answer is yes, please mark the box

Anemia
Celiac Disease
Chronic Constipation
Chronic Lung Disease
Chronic Pain
Cirrhosis
Colon Cancer
Colon Polyps
Crohn's Disease
Diabetes
Diarrhea
Diverticulitis
Esophageal Cancer
Heart Murmur
Heart Burn/GERD/Ulcers
Hemochromatosis
Hepatitis
Inflammatory Bowel Disease
Irregular Heart Rhythm
Irritable Bowel Syndrome
Kidney Disease
Liver Cancer
Pancreatic Cancer
Pancreatitis
Rectal Cancer
Sleep Apnea
Stomach Cancer
Stroke
Ulcerative Colitis

Past Surgical History:

Have you had any of the following surgeries? If the answer is yes, please mark the box

Abdomen Surgery
Appendectomy
Cardiac Bypass Surgery
Cholecystectomy
Colon Surgery
Colonoscopy
Colorectal Resection
Colostomy
Esophagus Surgery
Gastric Fundoplication
Hysterectomy
Joint Replacement
Liver Surgery
Pacemaker Insertion
Small Intestine Surgery
Stomach Surgery

Please list any additional surgeries:

Past Endoscopic History:

Have you had any of the following endoscopies? If the answer is yes, please mark the box, and complete the additional spaces.

Type of Endoscopy:

Colonoscopy/ Lower Scope

When:

Did they find Polyps:

Did they find Polyps

Type of Endoscopy:

Egd/ Upper Scope

When:

Did they find Polyps:

Have you had a problem with sedation or anesthesia? (describe)

History of Vaccinations and Inoculations:

Please mark the box if you have had the following vaccinations:

Hepatitis A
Small-Pox
Hepatitis B
Covid-19- Complete Series
Pneumovax (Pneumonia)
Measles
Flu Shot (For this season)
B.C.G.
Typhoid
Polio
Cholera

Allergies:

If you have experienced allergies to any of the following, please mark the box

None
Antibiotics (Please Specify Below)
X-Ray/ Radiology Contrast
Latex
Egg
Other (Please Specify Below)

Medications:

Please list the medications you are taking (prescription, over-the-counter, and supplements). Complete the column for dosage and mark the box for how often you are taking each medication. Attach additional pages if needed.

Medication Name:

Dosage:

Frequency

1x/day
2x/day
3x/day
As Needed

Medication Name:

Dosage:

Frequency

1x/day
2x/day
3x/day
As Needed

Medication Name:

Dosage:

Frequency

1x/day
2x/day
3x/day
As Needed

Medication Name:

Dosage:

Frequency

1x/day
2x/day
3x/day
As Needed

Medication Name:

Dosage:

Frequency

1x/day
2x/day
3x/day
As Needed

Social History:

Marital Status

Single
Married
Partnered
Divorced
Widowed

Children

How many?

Employment

Employed
Not Currently Employed
Disabled
Retired
Other

Occupation:

Alcohol Use:

Do you drink alcohol?

Yes
Not Currently
Never

How many drinks do you have per week?

Glasses of Wine

Cans of Beer

Shots of Liquor

Recreational Drug Use:

Have you ever used recreational or IV drugs?

Yes
Not Currently
Never

Which types:

Marijuana
Methamphetamines
Cocaine
Heroin

Form of use

Smoking
Snorting
IV
Oral Ingestion

Smoking/ Tobacco/Nicotine Use:

Have you ever smoked or used tobacco/ nicotine products?

Used for how many years:

When did you quit?

Cigarettes

Current Use
Former Use

Cigarettes per day:

Cigars:

Current Use
Former Use

Pipe

Current Use
Former Use

Nicotine Patch:

Current Use
Former Use

Chew Tobacco:

Current Use
Former Use

Vaping/ E-Liquid Use:

Have you ever used vaping or e-liquid products?

Yes
Not Currently
Never

If you use these products, do you use:

Every day
Some days

Used for how many years:

When did you quit?

Cartridges per day:

Which substances do you or have you used?

Nicotine:

Current Use
Former Use

Synthetic Cannabinoids

Current Use
Former Use

Nicotine-Salt:

Current use
Former use

Mix of Cannabinoids:

Current Use
Former Use

THC:

Current Use
Former Use

Flavored:

Current Use
Former Use

What types of devices do you or have you used?

Sexual Sphere

Are you sexually active?

Yes
Not Currently
Never

Are you sexual-minded?

Any excessive indulgence in sex in past and present?

Any effect on your health?

How do you feel after sexual intercourse?

Do you suffer from any sexual disturbance?

Any habit like masturbation like masturbation in past as well as present? If yes, how often?

Any homosexual inclination?

Did you suffer from any sexually transmitted disease?

Do you have increased or decreased for sex?

What is the method you use for family planning(contraception)

Any difficulty in erection?

Unwanted erection? Weak erection?

Menses: how are the periods; regular or irregular?

At what age did you start?

Was there any trouble then?

Mention interval between two period?

Mention number of days of flow?

Is there any change in quantity, colour, smell or consistency?

Are the stains difficult to wash?

Have you noticed any variation in quality and quantity in flow of menses? How? When?

Do you suffer in any way before, during or after the menses? (if yes, describe)

What symptoms did you suffer during menopause?

Do you feel internal parts coming down?

Is there any white discharge? (if so, mention colour, consistency and smell of discharge)

Do you pass gas from vagina?

Any trouble with breasts? (if yes, describe)

Appetite and Thirst

How is your appetite?

When you are hungry?

What happens if you remain hungry for a long time?

How fast do you eat?

How much thirst you have?

Any particular time you are especially thirsty?

Please select if you like/dislike the food or if the food disagrees.

Bitter

Like
Dislike
Disagree

Eggs

Like
Dislike
Disagree

Extra Salt

Like
Dislike
Disagree

Spicy Food

Like
Dislike
Disagree

Sweet

Like
Dislike
Disagree

Meat

Like
Dislike
Disagree

Sour

Like
Dislike
Disagree

Fish

Like
Dislike
Disagree

Bread

Like
Dislike
Disagree

Cabbage

Like
Dislike
Disagree

Butter

Like
Dislike
Disagree

Onions

Like
Dislike
Disagree

Fats

Like
Dislike
Disagree

Warm Food

Like
Dislike
Disagree

Milk

Like
Dislike
Disagree

Cold Food

Like
Dislike
Disagree

Coffee

Like
Dislike
Disagree

Fruits

Like
Dislike
Disagree

Mud/Chalk

Like
Dislike
Disagree

Anything Else

Like
Dislike
Disagree

Stool and Urination

Do you have any problems regarding you stools?

When and how many times a day you pass stools?

When is it urgent?

Do you have any problem about bowel movement?

Do you have to strain for stool? Even if soft?

Do you have belching or passing gas? Describe its character.

How do you feel after passing gas up or down?

Any problem about urine?

Any strong smell? Like what?

Do you have any trouble before, during and after passing urine?

Any difficulty about the flow? Slow to start, interrupted, feeble, dribbling, etc.?

Any involuntary urination? when?

Sweat/Perspiration-Fever-Chill

How much do you sweat?

Where and on what part do you sweat most?

Do you perspire on the palms or soles?

Is the sweat warm, cold, sticky, greasy, etc.?

What is the smell like? Foul, pungent, sour, urinous, etc.?

Any other symptoms after sweating?

What colour does it stain on the clothes?

Is the stain easy or difficult to wash?

Chest-Heat-Cold-Cough

Do you catch cold often?

Describe the symptoms, nature of discharge, etc.?

Is there any difficulty in breathing?

Is there any difficulty in your voice?

Do you have experienced any sense of cold or heat in any part of your body at any particular time?

Do you have cough?

Is it more at any particular time?

Any Complaints About:

Vertigo-do you have giddiness?

Faintness: do you ever feel fainted?

Headache-do you get headaches? (if so, how often)

Eyes and vision:

Ears and sense of hearing:

Nose and sense of smell:

Face and facial expression:

Mouth and sense of taste:

About lips (cracked, peeling of skin, etc.)

About teeth’s and gums:

Throat (including tonsils, etc.)

Any difficulty in swallowing?

Do you have pain in your back, limbs, joints? Describe:

If you have pains, do they shift?

In what direction do they extend?

Is there any abnormality, paralysis, numbness in any part of the body?

Is there any trouble with skin: such as itching, eruptions, ulcers, warts, peeling, etc.? (describe)

Any change in colour of the skin or spots of the body?

Is there any complaint about nails and skin around?

Is there any trouble with hair such as (falling, greying, dandruff, oily, poor or excessive growth, etc)?

Do wounds heal slowly?

Form keloid?

Do wounds tend to form pus?

Have you a tendency to bleed?

Are your troubles only one sided? Which one? Or more on one side?

Do they proceed from one to the other side? Or do they alternate or shift?

Is there any trembling? When?

Are there any senses of weakness? Where?

When is it more or less?

Is it in any particular part of the body?

MIND

It is universally acknowledged that your mind has tremendous influence on your body. For giving proper medication it is absolutely necessary for us to understand your emotional and intellectual nature. We can thus treat you as a whole.

In order to understand you; we will be asking some certain questions.

Answer them freely, carefully and completely.

Are you anxious?

Are you fearful of anything such as animals, people, being alone, death, robbers, sudden noises, thunder, of the future, high places, etc.?

Are you doubtful or suspicious? Of what??

What are you jealous about? Of whom? From what symptoms do you suffer when jealous?

In which matter you are impatient?

How long do you remember hurts caused to you by others?

How much revengeful are you?

What are you proud of? Does your proud get easily hurt?

Do you ever become suicidal? When? If so in what manner do you contemplate to end your life?

Even then, are you afraid of dying?

When are you cheerful?

Any unwanted thoughts in your mind any time? What are they?

Do you have any imaginary sensations or fears?

Do you hear voices, or that you are called, or anything else in this line keeps on occurring in your mind unduly?

How is your memory? For what is it poor? (e. G. Names, places, faces, etc.)

Do you weep easily? What makes you weep?

How do you feel after weeping?

How do you feel if someone offers you sympathy and consolation?

Are you easily irritated? What makes you angry?

What bodily symptoms you develop when you are angry? (Trembling, sweating)

Do you like company? Or like to remain alone?

How much are you affected by uncleanliness in your surrounding?

What are greatest griefs that you have gone through in your life?

What are the greatest joys that you have had in life?

What activities you deeply like?

In your opinion, which aspects of your mind and moods are not agreeable to you? Inspite of your awareness and maturity, are you unable to change these aspects?

Give a clearcut picture of your situation in life and your relationship with each of your family members, friends and associates in work?

How does the future look to you?

When you are free, what thoughts come to your mind?

Are you worried or unhappy over any personal, domestic, economic, social or any other condition? (If so, describe)

If asked for 3 desires or wishes in life, what will you ask for?

Sleep

Describe your posture in sleep, on the back, side, abdomen, etc.?

Are you able to sleep in any position?

In which position you cannot sleep?

During Sleep; Do you

Snore?
Sweat?
Keep Eyes Open?
Talk?
Moan?
Wake up with a Jerk?
Grind Teeth?
Dribble Saliva?
Keep Mouth Open?
Walk?
Weep?
Become Restless?

Describe if anything is unusual about your sleep: (sleepy, sleeplessness, etc.)

Do you have to uncover any parts?

Main complaints and other associated troubles: (and detailed history of the present illness. The onset and course with dates).

Origin of cause: can you track the origin of the present illness to any particular circumstance, accident, illness, or mental upset?

Tick the types of dreams that you have

Animals
Cats
Dogs
Snakes
Wild Animals
Robbers
Thieves
Anxious
Fearful
Ghosts
Travelling
Riding
Flying
Swimming
Drowning
Houses
Trees
Fruits
Water
Snow
Death, Whose?
Dead Bodies
Part of the Body
Suicide
Dead Persons
Being Hungery
Being Thirsty
Drinking
Eating
Fire
Lightning
Storm
Rain
Accidents
Falling
Shooting
Wars
Talking
Dancking
Singing
Pleasant
Money
Business
Day's Work
Forgotten Work
Vomiting
Passing Stool
Urination
Blood Bleeding
Excerments
Romantic
Rape
Sexual Sphere
Nakedness
Pain
Illness
Sickness
Multilations
Praying
Religious
Temple
Church
God
Failure/Exams
Unsuccessful Efforts
Being Unprepared
Missing Train
Griefs
Weeping
Vexation
Quarrels
Jealousy
Insults
Police
Imprisonment
Crime
Murder
Killing
Poison
Misfortunes
Insecurity
Danger
Being Pursued -By Whom?
Being Pursued -For What?
Are the Dreams -Coloured
Are the Dreams -Multicolored
Are the Dreams -Black & White
Physical Exertion
Mental Exertion
Fatigue
Of People
Children
Parties
Feasts
Of Events
Remote
Recents
Future
Marriage
Pprophetic

If any other: (specify below)

PLEASE READ THIS BEFORE FILLING THIS FORM

Family History

Provide information about them in the table below. Indicate yourself by writing ‘self’.

Have your blood relatives had any of the following? If yes, please mark the box.

Personal History

Review of Systems:

Past Medical History:

Past Surgical History:

Past Endoscopic History:

History of Vaccinations and Inoculations:

Allergies:

Medications:

Social History:

Alcohol Use:

Recreational Drug Use:

Smoking/ Tobacco/Nicotine Use:

Vaping/ E-Liquid Use:

Sexual Sphere

Appetite and Thirst

Please select if you like/dislike the food or if the food disagrees.

Stool and Urination

Sweat/Perspiration-Fever-Chill

Chest-Heat-Cold-Cough

Any Complaints About:

MIND

Sleep

Mohali Address

Chandigarh Address

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