Questionnaire is applicable to all.

Check whether you have asthma or not?

1.    Do you have repeated attacks of Cough, Cold, Sneezing, Dust allergy, Sinus Problems, Throat Irritation,Tonsils, Nose Block, Breathing Problems and Whistling sounds in the chest ?

2.  Do you have itching of eyes, nose, ears or throat or skin any time.   

3.  Is your above problems disturbing your sleep any time.

4.  Is your problems disturbing your work or profession or job.

5.  Do you worry about your future because of these problems.

6.  Is it disturbing your mental peace, social life and family life.

7.  Is anybody suffering with similar problem in your family or blood relatives.

8.  You visited many doctors, used many drugs - but you are not satisfied, is it so?

9.  Do you worry about - growth, studies, games, carrier, marriage, future, cost of
     treatment and side effects of drugs?

10. Are you suffering since long time with this problem?

11. Do you problems triggered by exposure to dust, weather changes, cool items,
      smoking or scents or perfumes or powders?

12. What you tried till now for your problems?

        Homeopathy                   Fish medicine                     Ayurveda                     Inhalers
 
        Nasal Drops                    Lodge Medicine                  Antibiotics & Cough Syrups

13. You have any other problem:

        B.P.                                 Sugar ( Diabates)                T.B.                                  Arthritis  
 
       Alcohol                            Heart Disease                      Smoking                         Pan & Gutka

       Acidity ( Gas trouble)         Cancer

Parant / Patient Signature: