FEED BACK FORM

Please answer the following Questions. Specify even the minute details even though
it does not seem important. You may answer YES, NO or NA ( Not applicable )

NAME           :
AGE            :
SEX            :
MARITAL STATUS :


01. EXPALIN YOUR COMPAINT AND HISTORY ( Add your explanation below )

02. GENERALITIES

   a. Do you like to listen to Music ?
   b. Do you take bath in Hot water ?
   c. Do you take bath in Cold water ?
   d. You like to remain in a cool atmosphere ?
   c. Like to remain Indoors ?
   d. Like Warm Rooms ?
   e. Do you like to dress neat and tidy ?
   f. You like casual dressing ?
   g. Like sweets ?
   h. Are you a smoker ?
   i. Consume Alcohol?
   j. Use narcotics ?
   k. You are Vegetarian/ Non Vegetarian ?
   l. Are you short tempered ?
   m. Do you feel angry over silly things ?
   n. Are you shy ?
   o. You are very bold ?
   p. Are you an extrovert ?
   q. Are you an introvert ?

03. MIND

   a. Are you a nervous person ?
   b. Are you anxious over simple matters ?
   c. Are you a person of hallucination ?
      ( Day dreaming )

04. SLEEP PATTERN

   a. You sleep lying down on back ?
   b. You sleep lying down on stomach ( face down ) ?
   c. You use more than one pillow while sleeping ?
   d. Do you see nightmares ?
      ( Like black animals / Snakes / being buried alive ...)
   e. Sleep Early ?
   f. Sleep Late ?
   g. You get very good sleep ?
   h. You do not get adequate sleep ?

05. HEAD ACHE

   a. Head ache during day time ?
   b. Head ache during Night ?
   c. Head ache after sleep ?
   d. Head ache before sleep ?
   e. Head ache after sunrise ?
   d. Head ache on the Right half of Head ?
   e. Head ache on the Left half of Head ?

06. EARS

   a. Feel itching ?
   b. Has discharge ?
   c. Hear Noises ?

07. FACE 

   a. Dou you have Pimples ?
   b. Did you have Pimples any time ?
   c. Do you have facial nerve pain ?

08. THROAT

   a. You have irritation ?
   b. Pain while drinking or eating ?

09. MOUTH

   a. What is the condition of your teeth ?
   b. What is the colour of your tongue ?

10. APETITE 

   a. Your eating habits ?

11. STOMACH / ABDOMAN / BOWELS

   a. Your stomach feels full even though you eat little ?
   b. Feel pain after eating ?
   c. You have constipation ?
d. You have Dysentry / Diarrhoea ?

12. KIDNEY / URINE 

   a. Feel pain while passing urine ?
   b. Burning sensation while passing urine ?
   c. Colour of urine ?
   d. Frequent urination ?
   
13. CHEST / RESPIRATORY

   a. Athsmatic ?
   b. Allergic ?
   
14. NATURE OF YOUR BODY

   Specify .. Like Fat, Slim, Slender, well built, Tall, short

15. SKIN

   Specify .. Like shiny, rough, fare, black, white


16. ANY OTHER