Since how long have you been suffering from this problem?
WeeksMonthsYears
Is there a family history of psoriasis?
YesNoNot Sure
Has it been increasing over a period of time?
Is your scalp affected with psoriasis?
YesNoOccasionally
Are your hands and legs affected with psoriasis?
Are your palms and soles affected with psoriasis?
Are there cracks/dryness in your palms and soles?
Does your problem increase during the winter?
Does it increase with stress?
Is there any itching in the affected region?
Is there any redness in the affected region?
Is there any scaling in the affected region? YesNoOccasionally
Is there any dandruff present?
Is there a lots of stress in your life?
Do you have any joint pains?
Are your nails discolored or disfigured?
Have you got any investigations done (if yes please mention the details of the results in the 'more symptoms' column)
YesNo
Are you already a patient with Dr. Manoj's Homeopathy? If yes then please give your Registration number in the ‘more symptoms’ column at the end of the questionnaire.
Name:
Email Address:
Contact Number:
Location/City:
Gender:MaleFemale
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More Symptoms:
