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About Dr Sonawane
Lichen Planus
Forms
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- Patient Form
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Contact Us

Home
About Dr Sonawane
Lichen Planus
Forms
- Book Appointment
- Patient Form
Photos
Videos
Contact Us

Lichen Planus Form

Patient Form

Please fill all details, especially the last box — it helps us evaluate your disease condition more accurately.

Name *

Email Address *

Age *

Religion

Phone No *

Birth Date

Gender

Occupation

Address

1) How long you are suffering from lichen planus? (write in days, months or in years)

2) On what parts of your body you have lichen planus?

Head
Face
Neck
Chest
Back
Abdomen
Hand
Feet
Palm
Soles
Legs
Thighs
Genitals
Other Parts

3) In what season your lichen planus is aggravated?

Summer
Winter
Rainy

4) In what season your lichen planus is ameliorated?

Summer
Winter
Rainy

5) Did any of your blood relative have or had lichen planus?

No one
Father
Mother
Brother
Sister
Uncle
Aunt
Other

6) Did you suffer from any major illness before?

Malaria
Typhoid
Jaundice
Worms
Headaches
Asthama
Theumatism
Tuberculosis
Diabetes
Any Skin Disease
Allergies
Cancer
Tonsilitis
Other

7) What are the major illnesses in your Father, Mother, brother, and sister?

Malaria
Typhoid
Jaundice
Worms
Headaches
Asthama
Theumatism
Tuberculosis
Diabetes
Any Skin Disease
Allergies
Cancer
Tonsilitis
Other

8) Have you been vaccinated for following diseases?

BCG
Polio
Triple
Rabies
Small Pox
Chicken Pox
Hepatitis B
Typhoid
Meningitis
Other

9) Did any animal or insect bite you before?

Dog
Cat
Rat
Monkey
Snake
Scorpion
Honeybee
Other Insects
Other Animals

10) Are you addicted to any drugs?

Alcohol
Tobacco
Smoking
Gutkha
Opium
Brown Sugar
Other

11) Did you have any grief, sorrow, vexation or emotional setback prior to lichen planus?

Yes
No

12) What are the treatments you have taken earlier and their result?

Allopathic
Ayurvedic
Homeopathy
Acu-Puncture
Other

13) Does your wound heal in time or not, does it suppurate easily?

Yes
No

14) What food items you crave for?

Sweets
Sour
Spicy
Salty
Bitter
Milk
Eggs
Meat
Fish
Chicken
Cold Drinks

15) What food items you hate to eat?

Sweets
Sour
Spicy
Salty
Bitter
Milk
Eggs
Meat
Fish
Chicken
Cold Drinks

16) Do you crave for salt, Clay, Chalk, etc?

Yes
No

17) What food items you can not tolerate or cause any trouble to you?

Sweets
Sour
Spicy
Salty
Bitter
Milk
Eggs
Meat
Fish
Chicken
Cold Drinks

18) How is your thirst?

Often
Hardly

19) How much do you sweat?

Heavy
Mild

20) Does your sweat have any odor?

Sour
Strong
Offensive
Other

21) Does your sweat leave any stain on your cloths, White, Yellow, Black etc....?

White
Yellow
Black
Other

22) How is your appetite? Normal, Less, More e.g. If you can not tolerate hunger or you are hungry at midnight?

Normal
Less
More

23) Do you have any digestion problem, Eructation, Flatulence, Acidity etc...?

Yes
No

What sun? 22)

24) How are you motions (stool)?

Normal
Regular
Unsatisfactory
Constipated
Other

25) Do you have any urinary problem?

Yes
No

26) Can you tolerate heat of sun? Summer?

Yes
No

27) Can you tolerate cold?

Yes
No

28) What water you prefer for bathing, cold, lukewarm, and warm?

Cold
Luke-warm
Warm

29) Do you need fan or air condition usually?

Yes
No

30) Do you need light or heavy covering in bed at night?

Yes
No

31) How do you sleep?

On Back
Side
Abdomen
Curled Up
Other

32) Do you sleep immediately after going to bed or it takes much time to sleep?

Immediately
Much Time Required

33) (a) Do you wake at night frequently or not?

Yes
No

33) (b) Do you wake by least noise?

Yes
No

34) (a) Do you get dreams?

Yes
No

34) (b) Any specific dream you always see?

Yes
No

35) (a) Describe your disposition?

Mid
Moderate
Irritable

35) (b) Are calm or hot tempered?

Calm
Hot

35) (c) Do you easily get anger?

Yes
No

35) (d) Can you control your anger?

Yes
No

35) (e) What do you do when angry?

Shout
Throw Things
Quiet

36) Do like company or enjoy being alone?

Like Company
Being Alone

37) Do you easily get nervous?

Yes
No

38) How do you react to contradiction?

Positively
Negatively

39) How is your confidence?

Less
Strong
Over

40) Do you weep easily or not?

Yes
No

41) Do you share your problems with other or keep it with you only?

Share
Don't Share

42) Do like consolation, to be helped, caressed or not?

Yes
No

43) Do you have any sexual problem?

Yes
No

44) How is your monthly cycle, regular, early, late?

Regular
Early
Late

45) Is it painful?

Yes
No

46) How is the quantity, scant, normal, and profuse?

Normal
Scant
Profuse
Other

47) (a) Do you have leucorrhoea problem?

Yes
No

47) (b) Describe in relation to occurrence?

Before Menses
After Menses
Always

47) (c) Quantity, its relation to monthly cycle?

Slight
Moderate
Copiuos

48) How many children you have? How was their birth, normal, difficult, forceps delivery, caesarian etc

Normal
Difficult
Forceps Delivery
Caesarian
Other

Any other thing you would like doctor to know? (write freely as it is seen by doctor only)

Expert Homeopathic Treatment for Lichen Planus & Psoriasis

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'Vijayshree' 2nd Floor, Karve Road, Pune 411004 INDIA
+91
9404447919
dr.sonawane@psoriatreat.com

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