Questionnaire for collecting Ethnomedicinal data during Ethnobotanical Study

Questionnaire:

Informants’ consent for the participation in the study:

I..................................................... (name of informant) hereby give my full consent and conscious to participate in this study and declare that to the best of my knowledge the information that I have provided are true, accurate and complete.

Date........................................                  (Signature/Thumb impression of Informant)

Informants’ details:

Name................................................................................................

Gender..............................................................................................

Age...................................................................................................

Occupation.........................................................................................

Education..........................................................................................

Location/Residence.............................................................................

Data about medicinal plant and its use:

Plant (Local name).............................................................................

Habit (Tree/ Herb/ Shrub/Climber/…...)

Plant part used...................................................................................

Cultivated/ Wild................................................................................

If cultivated, cultivated for……………………………….....................

If wild, availability in natural resources (easy/ difficulty/ very difficult)
Conservation needs ...........................................................................
Conservation efforts made by Government and local residents………..

Method of collection and storage……………………….......................

Name of disease(s) treated……………………………........................

Method of crude drug preparation........................................................

Mode of administration.......................................................................

Dosage .................................................................. .........................

Other uses (if any)…………………………......……...........................

Remarks:

Plant identified as ………………………………………… (Botanical name and family)

                                                                                               
Information provided by informants will be used for research purposes only

Signature of Researcher