Samarpit Homoeopathy -Booking

Address Address Line 1

Occupation (Nature of Work)

Previous diseases and drugs used

Typhoid

Cholera

Food poisoning

Worms

Diarrhoea

Dysentery

Measles

German Measles

Chicken-pox

Small-pox

Mumps

Whooping cough

Malaria

Jaundice

Any Liver Spleen or Gall bladder diseases

Miscarriage

Abortion

Currettings

Sickness during Pregnanacy etc.

Prolapse of uterus

Malnutrition

Rickets

Rheumatism

Backache

Any venereal disease like Syphillis Gonorrhoea etc.

Any heart trouble

Blood pressure, Giddiness

Nephritis (Kidney or urine trouble) Diabetes etc.

Tonsils operation

Abdomen operation

Appendix operation

Hernia operation

Piles operation

uterus operation

Renal stones operation

Gall stones

Phimosis operation

Hydocele operation

Cataract operation

Diptheria

Septic Tonsils

Adenoids

Recurrent infections

Sinusitis

Bronchitis

Eosinophilia

Cold-Fever

Chill

Pneumonia

Asthma

Pleurisy

T.B.

Any serious shock, grief, disappointments, fright, mental upset,depression or nervous break down

Chronic Headaches

Numbness

Cramps

Fits

Convulsions Polio

Paralysis

Meningitis - Any Lumbar puncture done

Any major accident or injury to body or head

Any occasion of unconsciousnesss

Skin diseases like Pimples, Boils, Carbuncles,Ringworms, Fungus, Scabies, Eczema, Herpes, Urticaria, Allergy. Ulcers on any part of the body

COVID-19

Disease suffered from

Approximate Age

Duration

Whether you compelety recovered

Medicines & treatment taken

Any other particulars

Personal History

Did your mother have any problem during Pregnanacy ?

Did she take any drugs during pregnancy? What were they ?

Was there any difficulty about your birth ? Give Details.

Your Habits

Smoking

Snuff

Chewing Tobacco

Alcohol

Tea

Sleeping Pills

Laxatives / Purgatives

Any other

MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES:(AND DETAILED HISTORY OF THE PRESENT ILLNESS, THE ONSET AND COURSE WITH DATES)

ORIGIN OF CAUSE: Can you trace the origin of the present illness to any particular cicumstances, accident , illness, or mental upset? (e.g. Shock, worry, errors in diet, overexertion, overexposure to cold, heat etc.) ?

Appetite and Thirst

How is your appetite?

When are you most hungry?

What happens if you have to remain hungry for long?

How fast do you eat?

How much thirst do you have?

Do you feel any change in your taste and feeling in your mouth?

Bitter food

Salt Extra

Sweet food

Sour food

Bread

Butter

Fats

Milk

coffee

Mud/Chalk

Spicy food

Cabbage

Onions

Warm food/drink

Cold food/drink

Fruits

Stool

Do you have any problem regarding your stools?

When and how many time a day you pass stools?

Do you have any problem about bowel movements?

Do you have to strain for stool? Even if soft?

Do you have belching or passing gas ? Describe its character

Urination & Urine

Any problem about urine?

Any problem smell? Like what?

Do you have any trouble before, during and after passing urine? After passing urine, sometimes 2-3 dropping of urine most of the time but not always?

Any difficulty about the flow? Slow to start, interrupted, feeble, dribbling etc.?

Any involuntarily urination? when?

Sweat/Perspiration - Fever - chill

How much do you sweat?

Where and on what part do you sweat most?

Do you perspire on the palms or soles?

Is the sweat warm, cold, clammy, sticky, musty, greasy, stiffens the linen etc.?

What is the smell like? E.g. foul, pungent, sour urinous

Chest - Heat - Cold - Cough

Do you catch cold often? If so, how?

Describe the symptoms, nature of discharge etc.

Is there any trouble with your CHEST or HEART? Is there any trouble with your voice or speech?

Is there any difficulty in breathing?

Do you have cough? Is it more at any particular time?

Sweat/Perspiration - Fever - Chill

What color does it stain the clothing?

Is the stain easy to wash off or difficult?

Any symptoms after sweating?

When do you get fever or chill? What brings to on?

Do you experience any sense of heat or cold in any part of your body at any particular time?

Do you have burning or heat in your palms or soles?

Sexual Sphere (General)

How is your sexual desire?

How do you feel after sexual intercourse?

Any particular feeling or symptoms appear before, during or after sexual intercourse?

Do you suffer from any sexual disturbance?

Any habit like (masterbation etc.) in past as well as present? How often?

Any homosexual inclination?

Did you suffer from any sexually transmitted disease? Syphillis? Genorrhoea? Herpes? HIV?

What is the method you use for family planning (contraception)?

Any difficulty in erection?

Wanted erection? Unwanted erection? Weak erection? Failing erection? Describe.

Any other trouble in sex? Describe in details.

Sleep

Describe your posture in sleep, on the back, side, abdomen etc.

Are you able to sleep in any position?

In which position you can't sleep?

During sleep do you

Check types of dreams that you have

Mind

It is now universally acknowledge that your mind has tremendous influence on your body. For giving proper treatment it is necessary for us to understand your emotional and intellectual nature. We can thus treat you as a whole in order to understand you we will be asking certain questions. Answer them freely, carefully and completely. This information will help us much in giving you the correct remedy. Also such a remedy will help improve your mental make up. Answer freely. Answer frankly. Answer completely.

Are you anxious? about which matters?

Are you fearful of anything such as animals, people, being alone, darkness, death, disease, robbers, sudden noises, thunder, of the future, of something unknown, high places, etc.?

Are you doubtful or suspicious? Of what?

What are you jealous about? Of whom? From what symptoms do you suffer when Jealousy?

In which matter are you impatient? Hurrid?

How long do you remember hurts caused to you by others?

How much revengful are you?

What are you proud of? Does your pride get easily hurt?

Depress, Brooding, etc.?

Do you ever become suicidal? when?

Select if you as child had any of the following qualities

Obstinacy

Temper Tantrums

Disobedience

Aggression

Hyperactivity

Destructiveness

Courage

Possessiveness

Competion - winning spirit

Sibling Jealousy

Any special skills

Unusual desires

Boasting

Stealing

Telling lies

Unusual fears

Shyness

Unusual attachments

Biting nails

Thumb sucking

Picking and playing with mother's body parts

Picking and playing with shawls, handkerchieves

Picking and playing with anything else

Religious

Dullness of memory

Slowness

Laziness/Indolence

Sensitive/Emotional

Please write in details, if the mother suffered from any physical or emotinal stress during pregnancy. Also describe the dreams the mother got during pregnancy.

Please describe any other aspects you feel are striking the child.

Describe one incident from the child's life when he/she very upset.

Booking

Adult Patient Case Form

Family history

List of major diseases