GENERAL DIRECTIONS FOR HOMOEOPATHIC TREATMENT
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?
HOW ARE YOUR COMPLAINTS OR PROBLEMS, BETTER OR HOW DO THEY BECOME WORSE? say Headache etc.
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?
Give in detail if any of your relatives (say Parents, Grandparents, Uncle & Aunty) are suffering or have suffered from the following.
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
Case Reference No.
Father’s / Mother’s Name
Profession / Occupation
Main Complaints (Detailed history of the present illness, the onset and course with dates and conditions of aggravation and relief)
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.
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.?
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