| Q.1 What is your present complaint? (Mention their duration) |
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| Q.2 If taken / taking any treatment including the use of pain killers or antibiotics. |
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| Q.3 What is the present status of
your blood tests (a) S. Creatinine (b) B. Urea / BUN (c)Hb% (d) Sodium (e)
Potassium (f) Phosphorous (g) Calcium |
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| Q.4 If you are Diabetic,
Hypertensive or both ? |
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| Q.5 What was the status of S.
Creatinine level when your kidney problem was diagnosed for the first time? |
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| Q.6 Are you undergoing Dialysis? If
yes what is the frequency per week? |
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| Q.7 If there is any history /
family history of kidney disease ( Kidney Failure, UTI, Kidney Stone, Cysts,
Strictures) |
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| Q.8 What is the size of both
kidneys according to your latest Ultrasonography report? |
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| Q.9 How much urine you are passing
in 24 hour (Approx.……….ml)? |
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| Q.10 What is the amount of Albumin /
Protein you are passing in urine according to your urine reports? |
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| Q.11 What is your present physical
complaint? (Mention their duration) |
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| Q.12 Whether you had any kind mental tension or prolonged anxiety, grief, mental trauma, shock as a result of death of spouse, child, friend or relative, humiliation, insult, being scorned, reproached, being punished, being dominated, fright, fear, bad news, horrifying incident ? Do you have a habit of suppressing Anger, Emotions or Desires? |
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| Q.13 Have you been disappointed due to loss of ambition, job, reputation, money, business failure, scientific failure, literary failure, unfulfilled love or deceived by friends or relatives ? |
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| Q.14 Whether you trace back illness to Puberty, Menopause, first / last / subsequent Pregnancies, Delivery, Abortion, Injury, Accident, Burn or any other Major Illness ? |
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| Q.15 How is your sleep ? What sort of Dreams do you see? Write in detail about Dreams (e.g. of accident, animals, intercourse, wedding, feasting, death of relative, own disease, water, drowning, falling, flying, ghost, traveling, murder, rape, robbers, of being pursued, of dying, dead body, future events, religious, unsuccessful efforts to do some work ? Whether your Dreams often repeat? |
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| Q.16 Do you feel scared or get frightened (e.g. of animals, when alone, in dark, of ghosts, thief or robbers, thunder storm, closed room or narrow places, accident, high places, water, misfortune, death, incurable disease ? |
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| Q.17 Do you feel better in company or while alone? Whether you try to be reserve? |
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| Q.18 What are your feelings regarding neatness, cleanliness or work being executed in order? Whether you like to wash hands and feet frequently? |
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| Q.19 Whether you get offended or vexed or angered easily? And how much time you take to be normal if you get upset ? Whether you try to find fault or criticize others? |
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| Q.20 Whether you are easily carried away by lucrative talks or emotions or you rely easily on others or you are suspicious? Do you feel sorry for anything or any work of yours? Do you have tendency to find fault in yourself or you are not satisfied with your work? Whether you are obstinate? |
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| Q.21 Do you have habit of biting nails, sucking clothes, thumb sucking? Do you have abnormal craving for chalk, clay, soap, raw rice, paper? |
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| Q.22 Whether you have habit of theorizing or making air castles or you think too much? Do you have strong desire to achieve something or any post? |
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| Q.23 Do you have tendency to find fault in yourself or you are not satisfied with your work? Whether you feel like taking revenge with some one or hate any body? |
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| Q.24 Whether you start weeping on least trouble? Does it relive or aggravate your trouble? Do you prefer to weep alone ? |
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| Q.25 Write in detail your delusions, illusions and hallucinations as someone is present behind you, presence of snake, as if someone is calling, being poisoned, people are talking about you, nobody takes care of you, nobody needs you |
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| Q.26 Do you lack confidence or you feel nervous or anxious in any special situation? |
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| Q.27 How is memory? Are you forgetful about names, figures, person or past events ? Do you lack concentration while reading or writing? |
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| Q.28 Whether you feel much heat in summers or much cold in winters in comparison to others? Do you feel any trouble in noise ,crowd, smell or at sight of blood? |
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| Q.29 Which particular thing you prefer or dislike to eat? (Write desire / aversion in order or preference for sour, sweet, salty, spicy, meat, fried, milk, chocolate, butter, tea, coffee) |
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| Q.30 Do you feel any trouble with above mentioned things? |
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| Q.31 Do you feel heat/burning/coldness in palms and soles of they sweat a lot? |
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| Q.32 Do you have a tendency to catch cold? |
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| Q.33 How much thirst do you feel? How often do you drink ? How many times and how much quantity of water do you take at a time? |
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| Q.34 Any other thing which you want to tell with regard to your health, Temperament , life style and also diseases of parents and relatives. Write in detail |
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| Q.35 ONLY FOR FEMALES Have you any trouble in periods/menses(in regularity,time,duration,flow or pain) |
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| Q.36 Whether you feel pain or any other trouble before, during or after menses? |
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| Q.37 Do you have any white discharge before, during, after menses or in between two periods? |
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