(Please use a separate
sheet of paper to answer questions)
Date of Birth:
What is your chief complaint (CC)?
2. When did this problem begin? Did something happen in your life
around that time? What do
3. What aggravates the CC? (weather, temperature, foods, movement,
4. At what time of the day is the CC the worst?
5. What symptoms/feelings accompany the CC?
6. Is there a specific kind of weather/season that bothers you?
7. How does a change of weather affect you?
8. How do you feel in bright sunlight?
9. Do you have any special reactions before or during a storm?
10. How do you react to drafts of air (e.g., an open window, a fan on
you)? Do you like to sleep
with the window open even when it is
11. How do you react to sudden changes in temperature, e.g., going out
into cold air, into a hot
room, etc.? Would you characterize
yourself as a "chilly" or "hot" person? For instance, does
it take a long time for you to warm up
in bed or do you prefer to throw the covers off?; do
like/dislike being next to a heater or
12. Do you like/dislike sitting, standing, lying, walking in open air?
13. Do you perspire a great deal? If so, when and where on your body?
14. Is there a time of day that tends to be a down time for you?
15. What worries you?
16. Do you cry easily? In what situations?
17. When upset, do you tend to tell other people or keep it to yourself?
18. When and on what occasions to you feel frightened or anxious?
19. What are the greatest griefs that you have experienced in your life?
20. What are your greatest joys?
21. What makes you sad, makes you feel the blues?
22. What bothers you most in other people? How, of at all, do you
23. Do you have a lack of self-confidence, a sense of low-esteem?
24. Do you have recurring dreams? Do they have a central theme?
25. What would you need to make you happy?
26. Ideally, what would you like to do for work? Is your work
27. If you won the lottery, what would you do?
28. How do other people view you?
29. Is there anything that you would like to change about yourself?
30. How do you feel before, during and after meals?
31. Are there specific foods that you crave?
32. Are there foods that you would not eat under any circumstances?
33. How much do you drink in a day? How thirsty do you tend to get?
34. How is your sleep? Do you tend to wake up at a particular time? If
35. How do you feel in the morning?
36. Number of pregnancies, of children, of miscarriages, of abortions?
37. At what age did your menses begin?
38. Are they (were they) irregular, early, late, etc.?
39. How do you (did you) feel before, during and after your period?
40. What diseases have you had? Have you had any childhood illnesses
twice, or in a very severe
form, or after puberty?
41. Do you have illnesses that recur periodically such as asthma, hay
fever, eczema, etc.?
42. Have you had any surgery? What and when?
43. Have you had vaccinations since the standard childhood ones? Have
you ever had an adverse
or unusual reaction to a vaccination?
44. How frequently do you get colds or the flu?
45. Have you had at any time:
Rashes, eczema, other skin
conditions: where? when? how treated?
a) Do you tend to need a smaller
dose of medications than other people?
b) Do you need less anesthesia than
others, or have a hard time coming out of it?
c) Are you sensitive to paint fumes,
exhaust, fragrances, etc.?
47. Family History:
Mention diseases, causes and ages of
death of the following:
48. Construct a time
line: Mention from childhood to the present the important
and physical traumas,
griefs, work-related events, diseases or traumas that your mother had
while pregnant with you,
etc. How did these events affect you at the time?
49. What else would you like to tell me about yourself or your