Visiting clinics at MUMBAI, VASHI, NAGPUR, NASHIK
psoriasis consultants puneHome homeopathic psoriasis treatmentsFAQ skin specialists puneClinical Form safe and effective treatment on psoriasisContact Us
 
    About Dr. R. S. Sonawane psoriasis specialist What is Psoriasis? psoriasis sun and water therapy Psoriasis Treatment psoriasis relief center Photo Gallery
psoriasis natural herbal supplement therapy

Clinical Form
 
* 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 nose?
 
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)
   
     
     
   
Copyright © 2008 Psoriatreat. All right reserved. Disclaimer Website Designed, Hosted and Maintained By
Tecmark India