Questionnaire for acute problems

(Acute complaints are those that resolve within a matter of days either of their own or through medication such as cold, fever, diarrhea, etc. During the course of your treatment, if you develop an acute complaint and feel that it will not resolve without medicinal intervention, you can use this form to report the complaint).

Describe your present complaint(s). What else goes with it?

What do you think is its cause (dietary errors, overexertion (mental and/or physical), injury, exposure to cold, heat, wetting, etc.)?

What does cause increase or decrease or relief of the complaint? (e.g. motion, sleep, posture, heat, cold, open air, when in room, light, noise, touch, pressure, eating, drinking, etc.)

When does the complaint get worse? (Morning, noon, afternoon, evening, midnight, night, etc.)

What are the things that interfere with your comfort (e.g. light, noise, presence of people, etc.)

Presence of any of the following: irritability, sadness, fear, placidity, restlessness, talkativeness, taciturnity, desire to have someone nearby, desire to be alone, etc.

Anything else?