Survey Form

Survey, Documentation, and Scientific Studies of Plant Remedies Used for the Treatment of Infectious Skin Diseases in Sindh

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 Annexure-I (Questionnaire) (Confidential)

 

Date/Time/Area/: …………………………………………………………..

A. Personal Information

  1. Name/Code:                         _________________________________________
  1. Cast:                                     __________________________________________
  1. Area/City/District:                  _________________________________________
  1. Language Spoken:                ________________________________________
  1. Birth Defect (if any):              ________________________________________
  1. Age:                                      ________________________________________
  1. Height:                                  ________________________________________
  1. Weight:                                 ________________________________________
  1. Address:                                 ________________________________________
  1. Marital Status: cousin marriage/non cousin marriage ___________________
  1. Number of Siblings:        ____________________________________________
  1. Number of Children (if married):           _________________________________
  1. Number of People in the House Hold:  _________________________________
  1. Economic Status (No. of Family members/Monthly income/No. of dependants)

             _________________________________________________________

  1. What is the highest level of school you graduated? Circle

a).      Illiterate                              

 b).     Literate         

c).      Graduated from primary school

d).      Graduated from secondary school 

e).      Graduated from high school

f).       Graduated from university

B.Medical Information

  1. Family History of skin disease(s) (please circle): 
  1. Allergies: List allergies to medications, foods, or chemicals
  1. Which part(s) of the body does pathogen affect?
  1. Description of the symptoms. List all of the possible effects on the body.
  1. How the infection is treated yet. Please circle

             a.         Antifungal                                    b.            Antibiotics 

             c.        Herbal medication                         d.            Other medicine?

  1. How the infection is diagnosed. What tests are done?
  1. Mode of transmission. How is the infection acquired?
  1. Duration of Disease
  1. What can be done to prevent getting this infection?

 

Name of disease

 

Name(s) of plants Part of plants used Mode of use
Fungal Skin

Infections

 

 

     
Athlete’s Foot(Tineapedis)

 

     
Jock Itch (Tineacruris)

 

     
Ringworm (Tineacorporis)

 

     
Breast fungus

 

     
Head Fungus (Tineacapitis)

 

     
Onychomycosis (Tineaunguium)

 

     
TineaVersicolor

 

 

     
Tropical Skin

Infections

 

 

     
Leishmaniasis

 

     
Leprosy or Hansen’s disease (HD)

 

     
Schistosomiasis

 

     
Scabies

 

     
Immunological Skin Infections

 

 

     
Psoriasis

 

     
Vitiligo

 

     
Pemphigus

 

     
Pemphigoid

 

     
Name of disease

 

Name(s) of plants Part of plants used Mode of use
Bacterial Skin Infections

 

 

     
Scalded Skin Syndrome 

 

     
Erysipelas 

 

     
Impetigo 

 

     
Acne

 

     
Pseudomonas dermatitis

 

     
Otitisexterna

 

     
Folliculitis

 

     
Necrotizing Fascititis

 

     
Viral Skin Infections

 

 

     
Molluscumcontagiosum

 

     
Shingles (Herpes Zoster)

 

     

C. Geographical Information

1. Area of the plant Collection:

2. Name of the plant/s:

3. Local name of the Plant/s:

4. Date of the plant collection:

5. Time of the plant collection:

6. Name of the person who collect the plant:

7. Part/s of the plant/s collected:

8. Altitude of Plant/s collection:

9. Climate at the time of Plant/s collection:

10. Voucher specimen/herbarium number: