This is a sample form.

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Diagnosis Questionnaire    

1. Present complaints.

You should furnish all the main problems you have at present  with their duration. In case of certain complaints which are not permanent and occur occasionally, you should mention details of their origin. Is it related to place, diet, food, occupation etc. ? Try to provide  maximum details about the symptoms.


2. History of present complaints.

You should give all the details about the history of the present complaint. The mode of onset of symptoms and the factors relieving the symptoms (eg: Rest, exercise, season, place,medication etc) should be submitted here.

3. History of past illness.

Furnish the details regarding the previous illnesses you have suffered from (eg.viral infections, injuries, systemic diseases) along with the age of onset, duration, outcome & residue.

4. Treatment history.

Mention the diagnosis if already known.Describe the treatments you underwent and medicaments / therapies you are undergoing  now. You should describe the order of use of the medicines and the response to the treatment.

5.Gynaecological History.

Please cover the following points in your information.
Age of menarche.

Whether the cycle is regular or irregular and the duration
Is the menstrual flow normal,scanty or excess. 
Are you taking any contraceptive pills.
Age of menopause
Whether menstruation is associated with any discomforts like pain,vomiting, giddiness etc.

Any abnormal discharge eg.leucorrhoea-Give details
Details of pregnancies & type of delivery.

6. Personal history
a. Atmosphere at the job, family or the society.
Does your disease or symptoms have any relation to  the above?Give details.

b. Bowel habits.
Time of the day when you usually go for bowel movements.
Colour of stool                                                             
Whether foul smelling                                                  
Regular or irregular ? associated with pain, burning sensation or itching ? any protrusion ?, blood spots or bleeding?

Towards particular food, medicines, dust, climate or others

d. Influence of climate or environment.
Describe briefly the type of climate and environment in which you live ? Is there any relationship to the climatic condition? Do these symptoms increase or decrease in a particular climate or environment ?

   7. Any other information that you  feel might help in making a proper diagnosis.
  8. Reports of any other clinical investigations. You may fill detailed reports into our ready formats which will load onto the screen when you press the submit key at the end of this page ,