Before filling in this questionnaire/case history proforma, the following directions should be kept in mind . In order to get the maximum benefit from our consultations we need to know ALL POSSIBLE DETAILS ABOUT YOUR AILMENTS. When answering the questions give maximum possible information especially in your own words, describing-

(i) particularly any peculiarities your might have noticed about yourself;
(ii) try avoiding medical terminology as far as possible and be as narrative as if describing complaints to a friend.

Numerous questions are posted before you covering the totality of your symptoms. In order to make a thorough and complete prescription, you will have to take pains to glance through all of them. Since HOMOEOPATHY TRIES TO TREAT THE TOTALITY OF THE SICKNESS i.e. the patient as a whole and not one or the other disease, the fuller the report, the better is the selection of the curative remedy.


In describing the complaints, try to give the specific location and sensation of complaints; how they appear or disappear and factors or conditions which increase or relieve the complaints. Any specific time that these are better or worse may also be mentioned.

If you have any complaints of PAIN — describe the sensation or pain in your own language — just as it feels to you.

e.g.: types of pain – cutting, boring, digging, soreness, aching, burning, cramp like, shooting, pressing, pricking, stitching, wandering etc.

Does the pain remain in one place or change place?

Describe, where the pain begins and where it extends to?

Is there any act or position, any part of the day or night, application of cold and warm water, or dry heat or cold, any changes with weather, cold or warm air or any other circumstances (Including emotional factors) that cause pain to be eased or worsen it or remove it entirely?

Does pain etc. comes suddenly and goes suddenly? or appears gradually? or disappears gradually etc?

Personal Details

Your Complaints

Your Complaints

Family History

Give in detail if any of your relatives (say Parents, Grandparents, Uncle & Aunty) are suffering or have suffered from the following.

Personal History

Kindly elaborate and mention habits, addictions like alcohol, smoking, drugs, tobacco etc

Previous Treatment Taken

Previous Treatment Taken

  • Personal Details
  • Your Complaints
  • Family History
  • Personal History
  • Previous Treatment Taken

Personal Details

Case Reference No.





Father’s / Mother’s Name



Present Weight

Present Height


Marital Status

Profession / Occupation


Contact No.


Email Address

Present Complaints

Main Complaints (Detailed history of the present illness, the onset and course with dates and conditions of aggravation and relief)

Complaint 1

Complaint 2

Complaint 3

Complaint 4

Complaint 5

Complaint 6

Origin or Cause

Past History (Previous Diseases And Treatment)

List of Diseases (Please Mention Blood Relations Affected)


Blood Relation Affected with Allergies


Blood Relation Affected with Arthritis

Blood Relation Affected with Cancer/Malignancy

Blood Relation Affected with Diabetes Mellitus

Blood Relation Affected with Hypertension

Blood Relation Affected with Heart Trouble

Blood Relation Affected with Tuberculosis (Pleurisy)

Blood Relation Affected with Gonorrhoea / Syphilis or STD

Blood Relation Affected with Psychiatric & Mental Disorders

Blood Relation Affected with Schizophrenia

Blood Relation Affected with Anxiety Neurosis / Depression

Any other sickness not mentioned above?


Appetite: What particular foods or drinks do you strongly crave for or desire please state your preference between 1 to 5 depending on strong likes & dislikes or aversion.


Salty Food

Do You Add Extra Salt In Your Food?

Sour Things / Pickles

Seasoned and Spicy



Fried and Fats

Any Other Cravings In Food?

Do you dislike specific food eg. sweets , salty etc

How is your Digestion?

Any complaints after eating for example-

Fullness of abdomen, Gas formation or Diarrhoea

Can you remain hungry for hours on end without?

1. Does any item of food cause any discomfort e.g. acidity, headache, flatulence etc.

2. Do you feel bloated, full and heavy after eating

How is your thirst? Please mention the grade of thirst between 1 to 5.


Stool / Bowel Movements

How many times do you move the bowels? When?


Any pain, burning, bleeding with stools?


Do you have flatus (wind) along with stools and is it noisy?


Frequency, day and night?

Any burning during urination?

Any difficulty in retaining urine? Do you have any incontinence while coughing or sneezing? Is the urine very urgent and you must rush immediately or it will escape?

Any associated complaints with urination?

Sexual Sphere For Men

Any sexual disturbances?

Disability of performance, premature ejaculation etc.?

Night Emissions?

Sexual Sphere For Women


Age of, appearance of first period (Menarche)?

How are the periods?

What is the duration of your period and how many days cycle?

How is the flow? – (scanty, heavy, clotted, any odour, colour)

Any complaints associated with, before or after menses?

(e.g.: Headaches, irritability, pre-menstrual depression, diarrhoea or constipation).

Any heaviness or pain in breasts before menses?

Any nodules in the breast or any other pre-menstrual symptoms?

Any leucorrhoeal discharge?

Character, colour, smell, when is it more?

Any Itching, burning or discomfort associated?

Any sense, of weight or bearing down at the time of menses?


How many times have you been pregnant?

How many children do you have and their age?

Did you take any medication during pregnancy?

Did you have normal deliveries?


Age of menopause?

Any associated complaints at time of menopause?

e.g.: Hot flushes, palpitation, anxiety, depression etc

Perspiration (Sweat)

1. Do you perspire a lot?

2. Any particular part of the body, that you perspire more on?

3. Any strong/offensive odour associated (e.g. sour etc.) with the sweat?

4. Does the perspiration stain the clothes?


1. Do you sleep well?

2. Any particular posture in which you sleep lying on the sides, back or on your abdomen etc?

3. Do you feel refreshed after sleep?

4. Do you dream while sleeping?

5. Any particular dream that is recalled and often repeated (e.g.: frightening dreams of falling from a height, or being pursued by some men, or dead people etc.)

6. Does any of your complaints get worse or better before, during or after sleep?


1. Any skin problem that you have had earlier? (e.g.: allergies, eczema, fungal infections pigmentation etc./enumerate type of skin lesion or eruptions or patches etc.)

2. Any treatment taken for it?

3. Any complaint or abnormality of Nails or skin around it?

4. Any complaint of Hair falling, early greying, dandruff, thinning etc.?

5. Any warts, moles birth marks on the body?

6. Does the skin heal normally or takes very long to heal? Any tendency to form excessive scar tissue (Keloids)? Any tendency for wounds to suppurate (form pus easliy)?

Previous Treatment Taken

Name of Disease

Medicines Prescribed

Systems of Therapeutics


Laboratory Tests

X-Rays, Scans, MRI etc.