QUESTIONNAIRE

Please give the answer of the fallowing questions in as great detail as possible. Things that you might feel are "medically not relevant" can give important information, such as your habits, patterns of behaviors, moods etc. So please report such things fully. Include any strange feelings and sensations that you think might be important, even if they are not specifically asked for in the questionnaire. Such information might give helpful information about your individual reaction to the illness, and thus help us prescribe the best medication for your problem. Of particular importance are changes that you have noticed recently, in appetite, in desire or aversion for particular foods, in behaviors, sleep patterns, bowel habits, dreams etc., so please report any such details that you have noticed.

1. NAME
2. AGE
3. EMAIL ADDRESS
4. MARITAL STATUS
5. FAMILY MEMBERS
6. EDUCATION DETAIL
7. OCCUPATION DETAIL
8. SELF EMPLOYED
9. SALIRED
10. NATURE OF THE OCCUPATION

FAMILY HISTORY:
Going all the way back to paternal and maternal grandparents.  (Allergies, skin problems, asthma, Alzheimer's, migraines, any other neurological disorders, heart problems, cancers, mental disorders, etc. For example, " Elder sister has/had eczema, paternal aunt died because of complications of heart disorders, maternal grandma had Alzheimer's," etc.

CHILDHOOD HISTORY:
(As far as you can remember) whether your delivery was normal or caesarian, whether there is a history of neonatal jaundice, measles, mumps, typhoid etc.  Any effects of vaccinations like fevers, loose bowels, frequency of colds, running nose, coughs.

Milestones of life (as far as you can recollect): teething, trying to sit up, walking, talking, etc. (on time, delayed, early).

History of broken bones, accidents, head injuries, dog/insect bites etc

GENERAL INFORMATION:

• How is your appetite
• Is there is teandency to indulge in particular kind of food  (eg: sweets, sour foods, salty foods, etc.)
• What kind of weather are you most comfortable in?
• Are you particularly uncomfortable in any weather or climate?
• Do sweat at all ? if yes then
• If you do, where do you sweat noticeably? (Scalp, upper lip, under arms, back, chest, etc.)
  Under what circumstances?
  (While eating, under tension, when you physically exert yourself etc.)
• In general do you like being out in the open air or do you feel more comfortable in closed rooms?
• Do you dream at all? If you do, do you remember them? What is the content?
  (eg: daily events, falling into space, running after a train, etc.)
• How is the quality of your sleep most of the time? (Rested and refreshed, feel tired most mornings etc.)
• How is your bowel habit?
  (Regular, constipated, diarrhea etc.) Is it modified by anxiety? By diet (eg. spicy food causes diarrhea)?

Provide details of all the questions mention above  as much as possible