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ONLINE CLINICAL FORM FOR PSORIASIS PATIENTS
(Fill this form and press submit button at the bottom of this page)

 
* indicates compulsory fields.
  Name of the Patient *
  Age (Yrs) *
  Sex * Male Female
 

Complete Postal Address

  Religion
  Occupation
  Tel/Mobile.No.*
  Email Id *
 
* Answer following questions briefly tick mark options where ever applicable?
 
1)  How long you are suffering from psoriasis?
 
  Year Month

 

2)  On what parts of your body you have psoriasis?
  Head        Face Abdomen Hand
  Feet Palms Soles Legs Thighs Genitals Any other parts

 

3)  In what season your psoriasis is aggravated?
 
Summer Winter Rainy season

 

4)  In what season your psoriasis is ameliorated? 
 
Summer Winter Rainy season

 

5)  Did any of your blood relative have or had psoriasis?
 
None Father Mother Brother Sister Uncle Aunt Other.

 

6)  Did you suffer from any major illness before?
 
Malaria Typhoid Jaundice Worms Headaces Asthama Rheumatism
Tuberculosis Diabetes Any skin disease Allergies Cancer Tonsillitis Other.

 

7)  What are the major illnesses in your Father, Mother, brother, and sister?
 
Malaria Typhoid Jaundice Worms Headaces Asthama Rheumatism
Tuberculosis Diabetes Any skin disease Allergies Cancer Tonsillitis Other.

 

8)  Have you been vaccinated for following diseases?
 
BCG Polio Triple Rabies Small pox Chicken pox Hepatitis B
Typhoid Meningitis Other        

 

9)  Did any animal or insect bite you before?

 
Dog Cat Rat Monkey Snake Scorpion Honey-Bee
Any other insect or animal Other          

 

10)  Are you addicted to any drugs?
 
Alcohol Tobacco Smoking Ghutka Opium Brown sugar Other

 

11)  Did you have any grief, sorrow, vexation or emotional setback prior to psoriasis?
 
Yes No

 

12)  What are the treatments you have taken earlier and their result?
 
Allopathic Ayurvedic Homoeopathy Acu-Puncture Other
         

 

13)  Does your wound heal in time or not, does it suppurate easily?
 
Yes No

 

14)  What food items you crave for?
 
Sweets Sour Spicy Salty Bitter Milk Eggs
Meat Fish Chicken Cold drinks Warm food Other  

 

15)  What food items you hate to eat? 
 
Sweets Sour Spicy Salty Bitter Milk Eggs
Meat Fish Chicken Cold drinks Warm food Other  

 

16)  Do you crave for salt, Clay, Chalk, etc...?
 
Yes No

 

17)  What food items you can not tolerate or cause any trouble to you?
 
Sweets Sour Spicy Salty Bitter Milk Eggs
Meat Fish Chicken Cold drinks Warm food Other  

 

18)  How is your thirst?
 
Often Hardly

 

19)  How much do you sweat?
 
Heavy Mild

 

20)  Does your sweat have any odor?
 
Sour Strong Offensive Other    

 

21)  Does your sweat leave any stain on your cloths, White, Yellow, Black etc....?
 
White Yellow Black Other    

 

22)  How is your appetite? Normal, Less, More e.g. If you can not tolerate hunger or you are hungry at midnight?
 
Normal Less More

 

23)  Do you have any digestion problem, Eructation, Flatulence, Acidity etc...?
 
Yes No

 

24)  How are you motions (stool)?
 
Normal Regular Unsatisfactory Constipated Other  

 

25)  Do you have any urinary problem?
 
Yes No

 

26)  Can you tolerate heat of sun? Summer?
 
Yes No

 

27)  Can you tolerate cold?
 
Yes No

 

28)  What water you prefer for bathing, cold, lukewarm, and warm?
 
Cold Lukewarm Warm

 

29)  Do you need fan or air condition usually?
 
Yes No

 

30)  Do you need light or heavy covering in bed at night?
 
Light Heavy

 

31)  How do you sleep?
 
On back Side Abdomen Curled up Other  

 

32)  Do you sleep immediately after going to bed or it takes much time to sleep?
 
Immediately Much time

 

33) ( a) Do you wake at night frequently or not?

 
Yes No

 

  ( b) Do you wake by least noise?
 
Yes No

 

34) ( a)Do you get dreams?

 
Yes No

 

  ( b)Any specific dream you always see?
 
Yes No

 

35) ( a) Describe your disposition? 
 
Mild Moderate Irritable

 

  ( b) Are calm or hot tempered?
 
Calm Hot

 

  ( c) Do you easily get anger?
 
Yes No

 

  ( d) Can you control your anger?
 
Yes No

 

  ( e) What do you do when angry?
 
Shout  Throw Things   Quit

 

36)  Do like company or enjoy being alone?
 
Like company   Being alone

 

37)  Do you easily get nervous?
 
Yes No

 

38)  How do you react to contradiction?
 
Positively Negatively

 

39)  How is your confidence?
 
Strong

 

40)  Do you weep easily or not?
 
Yes No

 

41)  Do you share your problems with other or keep it with you only?
 
Share Don't Share

 

42)  Do like consolation, to be helped, caressed or not?
 
Yes No

 

43)  Do you have any sexual problem?
 
Yes No

 

44)  How is your monthly cycle, regular, early, late?
 
Regular

 

45)  Is it painful?
 
Yes No

 

46)  How is the quantity, scant, normal, and profuse?
 
Normal Scant Profuse Other

 

47) ( a)Do you have leucorrhoea problem?
 
Yes No

 

  ( b)Describe in relation to occurrence?
 
Before Menses After Menses Always

 

  ( c)Quantity, its relation to monthly cycle?
 
Slight Moderate Copiuos

 

48)  How many children you have? How was their birth, normal, difficult, forceps delivery, caesarian etc
 
Normal Difficult Forceps Delivery Caesarian Other

 

  Other Details
(If Any)

 

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