Case Taking Questionnaire

It is not a bad procedure to say to the patient at this time: “ I have listened to you until now without interrupting you, now we will change the role, and please don’t be astonished if I seemingly stop you while answering, to ask you the next question, because this will mean that the answer I was waiting for is obtained. Do not believe that by so doing, I underestimate your answer , but this only signifies that a longer explanation will bring neither useful nor new details in the case.”

1. General Symptoms

  1. At what time in the 24 hours do you feel worst?
  2. In which season do you feel less well?
  3. How do you stand the cold, hot, dry, and wet weather?
  4. How does fog affect you?
  5. What do you feel when exposed to the sun?
  6. How does change of weather affect you?
  7. What about snow?
  8. What kind of climate is objectionable to you, and where would you choose to spend your vacation?
  9. How do you feel before, during and after a storm?
  10. What are you reactions to north wind, south wind, to the wind in general?
  11. What about draughts of air and changes of temperature?
  12. What about warmth in general, warmth of the bed, of the room, of the stove?
  13. How do you react to extremes of temperature?
  14. What difference do you make in your clothing in winter?
  15. What about taking colds in winter and in other seasons?
  16. How do you keep your window at night?
  17. What position do you like best — sitting, standing, lying?
  18. How do you feel standing a while, or kneeling in church?

You remark that this question of the standing position comes again. You will find this way of repeating it is intentional here and there in the questionnaire. It is a very useful and necessary procedure for verification.

  1. What sports do you engage in?
  2. What about riding in cars or sailing?
  3. How do you feel before, during, and after meals?
  4. What about your appetite, how do you feel if you go without a meal?

It will be often answered to you: “I can easily go without a meal but I never can stand a big dinner or banquet.” A question that you did not ask, but which demonstrates that the question was well formulate as it made the patient talk and left him his own choice.

  1. What quantity and what do you drink? What about thirst?
  2. What are the foods that make you sick, and why?

If the patient does not answer after a while, just ask looking closely at him: sweets, salty things, sour, greasy food, eggs, meat, pork, bread, butter, vegetables, cabbages, onions, fruits?

  1. What about wine, beer, coffee, tea, milk, vinegar?
  2. How much do you smoke in a day, and how do you feel after smoking?
  3. What are the drugs to which you are very sensitive or which make you sick?
  4. What are the vaccinations you have had, and the results from them?
  5. What about cold or warm baths, sea baths?
  6. How do you feel at the seaside, or on high mountains?
  7. How do collars, belts, and tight clothing affect you?
  8. How long are your wounds in healing, how long in bleeding?
  9. In what circumstances have you felt like fainting?

2. Mental symptoms

During all these questions, the physician must by kind words, put his patient at ease, but must watch him very closely, without the patient’s noticing it.

  1. What are the greatest griefs that you have gone through in your life?

Quite often the patient will lower the head and look quite moved, and a kind word of the doctor will be needed. It is why, as soon as the extra-version of self-expression has been made, this following question will make the patient look at you again in an astonished way, and sometimes with a happy smile.

  1. What are the greatest joys you have had in life?

These two questions are very important and, when asked at the right moment, will pave the way for the coming questions.

  1. At what time in the 24 hours do you feel blue, depressed, sad, pessimistic?
  2. How do you stand worries?
  3. On what occasions do you weep?

If the patient cannot answer, we will just ask — not losing for one second his expression — music, at reproaches, at which time of the day? Certain people can refrain from weeping, some others cannot.

  1. What effect does consolation have on you?

If the answer is “It depends by whom,” you may say: “Just by people you like,” because very often people say they do not like to be comforted because they think of members of their family they hate.

  1. On what occasions do you feel despair?
  2. In what circumstances have you ever felt jealous?
  3. When and on what occasions do you feel frightened or anxious?

If the patient does not answer, ask: “Some people are afraid of the night, of darkness, to be alone, of robbers, of certain animals, of death, of certain diseases, of ghosts, to lose their reason, of noises at night, of poverty, of storm, of water.” According to the way of answering, you will at once see the real fears, and be able to discriminate those which are not to be taken into consideration.

  1. How do you feel in a room full of people, at church, at a lecture?
  2. Do you go red or white when you are angry, and how do you feel afterwards?
  3. How do you stand waiting?

If he does not answer, just question him about impatience.

  1. How rapidly do you walk, eat, talk, write?
  2. What have been the complaints or effects following chagrin, grief, disappointed love, vexation, mortification, indignation, bad news, fright?
  3. In time of depression, how do you look at death?

Certain patients have presentiments of death, thoughts of death, ever desire to die; other have tendencies or desires of suicide, some would be courageous enough to do it, others are afraid, in spite of desiring it.

  1. Tell me about over-consciousness and over-scrupulousness, about trifles; some people do not care about too many details and too much order.
  2. What about your character before, during and after your period?

3. Food cravings and aversions

Of course, all these questions have been already asked in the beginning of the questionnaire, but by asking them again, you are able, by doing some cross-questioning, to determine if they have been answered well the first time or not.

  1. What is the kind of food for which you have a marked craving or aversion, or what are those that make you sick or you cannot eat?

Here, also, it is very important to watch very carefully the expression of the atient, because it is very easy to read on the face by observing the corners of the mouth coming down if the patient is disgusted, or on the contrary coming up with big shining eyes if the craving or a strong alimentary attraction is felt. Then, one can add, for example:—

  1. What about pastry and sweets?
  2. What about sour or spiced food?
  3. What about rich or greasy food?
  4. How much salt to you need for your taste?
  5. What about thirst and what do you drink? Coffee wine, beer, etc.

4. Sleep

  1. In which position do you sleep, and since when that position? Where do you put your arms, and how do you like to have your head?
  2. What are you doing during sleep?

If the patient doesn’t answer, you add: “Some people speak, laugh, shriek, weep, are restless, are afraid, grind their teeth, have their mouth or their eyes open.”

  1. At what time do you wake up, or when are you sleepy? What makes you restless or sleepy?
  2. What about dreams?

5. For Ladies, Menses

  1. At what age did they begin?
  2. How frequently do they come?
  3. What about their duration, abundance, color, odor, what about clots, etc.
  4. At what time in the 24 hours do they flow most?
  5. How do you feel before, during, and after menses?

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