Dr. Nitesh Jain's questionnaire, from India, to structure the anamnesis of students and professionals who wish to do so.

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sandesh4nitesh@rediffmail.com

+919725934037

Dr. Nitesh Jain.

CONSULTATION FORM

Date of recording –

1. Patient’s Information. Reference –

1. Name –
2. Nick Name –
3. Age –
4. Sex –
5. Number of siblings and your number –

6. Married/Bachelor/Widow/Widower –

• Age when married –
• Marriage was at own will or some other reasons!

• If widow or widower then mention age and regarding occurrence of incidence.

• What was the reaction on hearing the news?

• What was the first thought that came on receiving the news?

7. Occupation –

• If changed (Profession or place of work) then mention the time of change.
• Name previous profession or place of work?
• Reason for leaving previous profession or place?

8. Complete postal address –

9. Country –
10. Telephone Number –
11. Fax Number –
12. Mobile Number –
13. E-Mail Id –

1. Appearance –

1. Complexion –
2. Height –
3. Weight –
4. Any Deformity –
5. What is the best part that you like in your appearance?

6. What is that you generally get compliment from others in your appearance?

7. How you react on receiving the compliment?

8. What is the worst part that you dislike in your appearance?
9. If anyone nags on that part, what is your reaction?

2. Presenting Complaint.

1. Please mention in detail about the nature of complaint that brought you for consultation which includes (If there is more than one presenting complaint then follow the headings given below to furnish the detail of next complaint )–

• Part affected –

• Internal Feeling in affected part –

• External feeling in affected part on touch –

• If noticed mention the factors that increases or decreases the complaints in relation to position, motion, temperature, time of day, moon phase etc –

• Duration of presenting complaint –
• How the presenting complaint started?
• Any previous treatment of this complaint and its response –

2. Mention any other complaint if related to the chief complaint like:

• Any complaint which comes and goes with the presenting complaint?

• If any complaint comes then the main complaint goes away but main complaint returns at once on disappearance of the other complaint?

• Any other complaint of which you are habitual for long time?

3. Childhood History.

1. Were you born in due time?
2. Had any problem occurred during labour, if yes mention in detail about the problem and its management.

3. Your weight at birth, normal or underweight?
4. You cried easily at birth?
5. Do you have any birth mark, if yes elaborate it.

6. Did you learn to speak, walk and talk in time.
7. Had your sutures closed in time?
8. Was your teething on time?
9. Had any problem occured during dentition like diarrhea or fever, mention elaborately.

4. Past History.

1. Write about the major diseases you have suffered after birth till present in sequential order of age along with the treatment taken and its outcome. Mention about hospitalization and blood transfusion.

2. When you were in mother’s womb did she suffer from any disease, any stress, trauma – mental or physical. If yes, mention in detail about her reaction to the incident.

3. Were you injured anywhere, any accident, operation – if yes mention about the time, nature of injury, part affected, treatment taken, response of treatment and present condition of the part.

4. Have you bitten by any animal like dog, snake, monkey, or other animal even human may be child which caused bleeding, if yes mention about the time, nature of injury, part affected, treatment taken, response of treatment and present condition of the part.

5. Have you suffered any emotional crises, if yes mention in detail about the time and nature of incident with your reaction to the incident.

6. Presently if the incident strikes your mind what you feel regarding it?
7. Have you taken Vaccination, Inoculation, Triple Antigen, Anti Tetanus Serum, BCG, DPT, MMR, Oral Polio, X – ray, Radium therapy etc since your childhood – mention in details, also mention about reaction if you suffered from any of them.

5. Personal History.

1. What type of clothing do you prefer – loose or tight fitting and why?

2. Do you catch cold easily?
3. Mention about your habits, addiction or regular use of medicine like tonics, analgesics, tranqulizers, purgatives etc.

4. Any bad habits?

5. Mention the unchanged thing in you since childhood.

6. What you wanted to change in yourself and why?

7. Did you tried to change and what was the outcome?

6. Family History.

1. Mention diseases that your parents, grandparents and relatives on maternal and paternal sides had suffered including your blood relation like brothers and sisters like carcinoma, tuberculosis, diabetes mellitus etc.

2. If anyone died of any disease then mention the disease and age of deceased.

3. Any history of suicide in your blood relation or attempted suicide?

4. Any history of miscarriage, abortion, premature death or still birth of your mother or wife?

7. Physical Generals.

1. Reaction to heat and cold –

• Can you tolerate sun light and heat or suffer from headache, photophobia etc.
• What is intolerable – summer or winters?
• Is summer intolerable because you don’t like stickiness of much sweating?
• How many clothes you wear in winters?
• In summers if electricity goes off what is your response?

2. Thirst –

• What about your thirst?
• Do you relish chilled water or normal water?
• What amount of water do you take in one sitting?
• What is the time interval between drinking water?
• Suppose you are doing any work at that time do you forget about food and water to drink or you feel thirsty and you have to drink?

3. Appetite –

• What about your appetite and satiety?
• Can you tolerate hunger, if no then what happens when you are empty stomach?

• At what time of the day do you mostly feel hungry?

4. Desire –

• You are vegetarian or non vegetarian?
• Do you prefer warm food?
• Which taste you like more?
• Is there any food item without eating which you don’t feel comfortable or you cannot live, If yes mention.

• Previously had you had abnormal desire like ash, earth, lime, chalk etc.

• What type of drinks do you prefer – chilled or normal?

5. Aversion –

• Which taste you want to avoid and why?

6. Intolerance –

• Is there any specific food which precipitates any problem, if yes mention in detail.

7. Salivation –

• Your mouth remains dry or moist?
• Has anyone told you regarding offensive smell from your mouth?
• In sleep does saliva dribbles off your mouth and wets pillow or bed sheet.

8. Taste –

• What is normal taste of your mouth?
• While eating does any taste is felt more or less than others?
• Is there any taste that is not felt by you?

9. Vision –

• Is your vision normal?
• Do you face problem in opening eyes in bright light – sunlight or other light?

10. Hearing –

• Is your hearing normal?
• Do you hear any sound more or less everytime, if yes mention in detail.

11. Smell –

• Is your smelling sense normal?
• Does any smell felt more or less by you?
• If anything gets burnt then is it you among 5-6 persons sitting who notices it first.

• Does any smell felt by you every now and then, if yes mention in detail.

12. Touch –

• Are you much ticklish, if yes which part?
• Which part you don’t like tight clothings?
• What is your reaction if anyone touches you consciously or unconsciously?

13. Integument –

• Your skin is dry, rough, oily or smooth?
• Do you have any specific problem that occurs in summers or in winters?

• Do you have any persistent skin problem?
• On receiving any form of cut does blood stops normally or it takes long time to stop bleeding?

• If you are wounded does wounds heal normally or it takes much time to heal explain what happens in that time period?

• After healing had any mark remains on the site of injury describe it in details.

14. Perspiration –

• You perspire more or less?
• Which part you sweat more?
• Sweat is cold or hot?
• Is sweat more offensive?
• After drying does any stain remains on clothes?
• Sweating makes you feel better or not?

15. Sleep –

• Your sleep is deep or light?
• Do you wake up in mid sleep, if suddenly you wake up in middle of night, then you can sleep afterwards or not?

• After awaking from sleep do you feel to sleep a little more or you are refreshed?
• In which position you are comfortable in sleeping?
• You sleep still or do some activities, if any activities like teeth grinding, kicking, snoring, talking, walking, are done mention elaborately.

16. Dream –

• Do you see dream in sleep or sleep dreamless sleep?
• Do you remember the dreams?
• Is there any peculiarity regarding your dream?

• Is there any particular type of dream that you see every now and then, explain about its frequency, how it begins, what you feel, and how it ends?

• At times do you get frightened in dream and awake up in fright, if yes explain.

• If you cannot sleep after getting frightened in dream, then what you do or ponder about.

17. Stool –

• What type of lavoratory do you use for defecation?
• Are your bowel cleared everyday in morning?
• Are you satisfied by your bowel habit?
• What is the character of your stool, its colour, consistency, odour?

• Does it require much straining to evacuate?
• Do you feel pain during, before or after defecation?

• Does blood passes from rectum before, after or during defecation, if yes explain its amount, colour, consistency, flow.

18. Urine –

• What is the nature of your urine, its colour, smell, flow?
• Is there burning before, during or after urination, if yes explain its sensation.

• Does any time blood comes out while urinating?
• Is your bladder control normal?

19. Sensation –

• Do you have any chilliness or burning sensation in palm, soles or vertex?

• Do you have any other sensation in any body parts?

20. Sexual symptoms –

• What about your libido?
• Did you have habit of masturbation?
• Do you have any pre marital sexual relation, explain in detail its reason of indulgence.

• What is your sexual fantasy?

• Is there any problem in your sexual organ?

• Do you enjoy sexual intercourse?

1. Specifically for males.

• When fully erect your penis is vertical or is tilted to one side, which side explain.

• Do you have any problem with erection, premature ejaculation if yes explain in detail.

• After ejaculation what is your feeling?
• Do you have any problem before, during or after ejaculation, if yes mention elaborately.

• What is the colour, consistency, smell and taste of your semen.

2. Specifically for females.

• At what age was your menarchy and menopause?
• Was there any problem during menarchy and menopause?

• Is your menstrual cycle regular or irregular, mention number of days cycle?

• How many days does menses remain?

• What about the flow of blood – regular or irregular?

• What is the character of the blood, amount, colour, consistency, smell etc?

• Are there any symptoms that occurs before, during or after menstruation?

• Is there pain before, during or after menstruation, if yes mention the character of pain, extention, any modifying factor as before?

• Stain of menstrual blood is washable or not?
• Do you suffer from leucorrhoea or any other discharge, if yes mention in detail about its time of appearance, colour, amount, consistency, smell, acrid or bland, does it leaves stain?

• Its how long that you are married?
• Is your married life satisfying, if no explain in detail.

• How many children do you have, mention the birth of children in chronological order, with reference to your age at that time, nature of delivery?

• Is there any history of abortion – induced or spontaneous, if yes explain.

8. Life span

• What is the speed at which you work?
• Write briefly about your nature during childhood.

• Write briefly about your present personality.

• Explain in short what you wanted to be, what you are and what you look forward to do.

• Mention in detail some incidents in which you had to take your decision alone.

9. Mental Generals.

• What is that you feel so funny about yourself?

• As far as you can remember when ever any stranger came to house do you approach them or felt uneasy to face them?

• What type of student were you at school?
• What was your favorite subject, why?

• Were you regular at school, if yes why and if no why?

• Were your parents after you to complete homework or study, if you did it yourself what was the reason?

• How many friends did you have in school, generally boys or girls?
• Are they still in contact with you?
• Do you share all problems with your friends, if no why?

• What is your hobby and why?
• What is that you hate doing for others and why?

• What is that you want others to do for yourself and why?

• What about your memory?

• Do you have any fear, if yes mention clearly.

• How frequently do you believe in someone and what is its outcome?

• How frequently do you take decision and how far are they right?

• Do you have any problem in understanding any new function of electronic items like computers, digital cameras, mobile phones etc.

10. Physical Examination.

• Inspection –

• Palpation –

• Percussion –

• Auscultation –

11. Pathological Investigations (Mention date of investigation with reference range)

• Blood –

• Stool –

• Urine –

• Sputum –

• X-Ray –

• Ultrasonography –

• E.C.G –

• E.E.G –

• M.R.I –

• C.T Scan –

• Other reports –