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Case History Questionaire

Please answer the following questionaire and submit the form. The doctor will review it and get back to you after reviewing your case history.

  • Name 
  • Email 
  • ID
  • Gender(F/M)
  • Age 
  • Qualification 
  • Answer YES or No for the following:
  • Emotional_Tension 
  • Social_Isolation 
  • Unloved? 
  • Unattractive? 
  • Self_Centered?
  • Over_Dependency
  • Short_tempered 
  • Immaturity 
  • Restlessness 
  • Sleeplessness 
  • Stress_in_family 
  • Stress_at_work 
  • Lack_of_education 
  • Lack_of_security 
  • Identity_Crisis 
  • Sexual_Problems 
  • Aged_Parents 
  • Prolonged_Illness 
  • Accident_Proneness 
  • Excessive_Abesenteei 
  • Alcohol_Dependence 
  • Fincial_Difficulties 
  • Dominating_Parents 
  • Bad_Habits 
  • Headaches 
  • Dizziness 
  • Stomach_Problems
  • No_Appetite 
  • Feel_tensed 
  • Tremors_and_ties
  • Depressed 
  • Feel_Lonely
  • Sucidial_Ideas 
  • Unable_to_relax 
  • Inability_to_make_decision
  • Cannot_make_friends_
  • Concentration_difficulty
  • Guilty_and_morally_w 
  • Worrying_over_failures 
  • Inablity_to_cope_up_ 
  • Failure_to_use_creativity
  • Failure_to_Inentify_
  • Lack_of_physical_strength 
  • Lack_of_psycho_motor
  • changes_in_health_condition
  • Changes_in_economic_ 
  • Unrealistic_love_need 
  • Inablity_to_express_
  • Inablity_to_accept_f
  • Inablity_to_accept_a 
  • inablity_to_accept_r 
  • Cannot_meet_social_e 
  • Lack_of_Job_satisifaction
  • Inablity_to_face_stress 
  • Inablity_to_face_a_c 
  • Lack_of_flexibility_
  • Nagative_attitude_at 
  • Unrealistic_self_con 
  • Unrealistic_Marriage
  • Cannot_understand_op 
  • Unrealistic_parental
  • cannot_do_anything_r 
  • changes_in_job_respo 
  • communication_problem 
  • Lack_of_adjustments
  • full_of_regrets
  • Learning_difficulties 
  • misunderstood
  • lack_of_motivation 
  • changes_in_value 
  • lack_of_confidence
  • Early/Late_marriage
  • Unrealistic_goals 
  • High_fustration
  • Lack_of_competition 
  • Lack_of_cooperation
  • Emotional_imbalance 
  • lack_of_training 
  • unhappy_childhood 
  • peer_pressure
  • improper_aspiration
  • Disuse_of_potentials 
  • Less_job_experience 
  • Get_hurt_easily
  • Death_in_family 
  • sickness_in_family
  • Horrible_thoughts 
  • Nightmares 
  • Shy_with_people
  • Fatigue 
  • Memory_problems 
  • worthless_stupid 
  • Fears_anxiety
  • Aggressive 
  • Frequent_Job_change 
  • Job_complaints
  • Stammering
  • Negative_thinking
  • Handling_children