YOUR NAME *

YOUR AGE *

YOUR GENDER *MALEFEMALE

PHONE NUMBER *

E-MAIL *

YOUR PROFESSION

ADDRESS

COUNTRY *Select your CountryAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAustrian Empire*AzerbaijanBaden*Bahamas, TheBahrainBangladeshBarbadosBavaria*BelarusBelgiumBelizeBenin (Dahomey)BoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBrunswick and LüneburgBulgariaBurkina Faso (Upper Volta)BurmaBurundiCabo VerdeCambodiaCameroonCanadaCayman Islands, TheCentral African RepublicCentral American Federation*ChadChileChinaColombiaComorosCongo Free State, TheCosta RicaCote d’Ivoire (Ivory Coast)CroatiaCubaCyprusCzechiaCzechoslovakiaDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicDuchy of Parma, The*East Germany (German Democratic Republic)*EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFederal Government of Germany (1848-49)*FijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGrand Duchy of Tuscany, The*GreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHanover*Hanseatic Republics*Hawaii*Hesse*Holy SeeHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKingdom of Serbia/Yugoslavia*KiribatiKoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLew Chew (Loochoo)*LiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMecklenburg-Schwerin*Mecklenburg-Strelitz*MexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueNamibiaNassau*NauruNepalNetherlands, TheNew ZealandNicaraguaNigerNigeriaNorth German Confederation*North German Union*North MacedoniaNorwayOldenburg*OmanOrange Free State*PakistanPalauPanamaPapal States*Papua New GuineaParaguayPeruPhilippinesPiedmont-Sardinia*PolandPortugalQatarRepublic of Genoa*Republic of Korea (South Korea)Republic of the CongoRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSchaumburg-Lippe*SenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon Islands, TheSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTajikistanTanzaniaTexas*ThailandTimor-LesteTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluTwo Sicilies*UgandaUkraineUnion of Soviet Socialist Republics*United Arab Emirates, TheUnited Kingdom, TheUruguayUzbekistanVanuatuVenezuelaVietnamWürttemberg*YemenZambiaZimbabwe

BRIEF DESCRIPTION OF THE PROBLEM *

HOW DO YOU COPE WITH THE DISEASE I.E., WHAT THE DISEASE FORCES YOU TO DO ? *

DO YOU EVER THINK ABOUT YOUR DISEASE OR NOT? IF YES WHAT IS THE THOUGHT PROCESS? *

WRITE ABOUT YOUR NATURE IN GENERAL? *

ANY CHANGE IN MOODS DURING THE SICKNESS, PLEASE EXPLAIN ? *

HOW DO YOU HANDLE YOUR ANGER? *

LIKING FOR MUSIC? *

PLEASE EXPLAIN YOUR LIKES/ DISLIKES OR ANY SENSITIVITY TO FOOD? (EG. SPICY, OILY, FATTY, EGGS, FISH ETC) *

WHICH WEATHER YOUR BODY CAN TOLERATE? (E.G. HOT OR COLD) *

YOUR APPETITE, THIRST, SLEEP & BOWL MOVEMENT. PLEASE EXPLAIN. *

MENSTRUAL HISTORY (IN CASE OF FEMALES)?

ANY OTHER INFORMATION OR SYMPTOM WHICH YOU FEEL IS RELEVANT & CONNECTED WITH THE MAIN DISEASE

PROBLEMS, IF ANY, DURING PREVIOUS PREGNANCY?

IN CASE OF PROBLEMS OF CHILDREN, MOTHERS PLEASE WRITE WHAT WAS YOUR MENTAL STATE DURING THE PERIOD OF PREGNANCY?

PLEASE WRITE ABOUT YOUR NEGATIVE EMOTIONS, IF ANY, AS THEY WILL HELP IN THE SELECTION OF THE APPROPRIATE REMEDY? *

HOW DID YOU SPEND YOUR CHILDHOOD ? DID YOU GET THE LOVE, CARE AND NURTURING FROM THE PARENTS ? *

HOW DID YOU SPEND YOUR SCHOOL/COLLEGE/UNIVERSITY DAYS? PLEASE ELABORATE*

WERE YOU GOOD AT MAKING FRIENDS OR FELT FRIENDLESS? *

DID YOU FACE ANY TEASING, JESTING, RACIAL REMARKS OR MOCKING FROM ANY ONE AT ANY STAGE OF YOUR LIFE? *

IN THE AREA OF RELATIONSHIPS , DID YOU EVER FEEL BOTHERED BY ANY RELATION. IF SO HOW? WHAT KIND? *

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