Adult Homeopathy Case Record Form

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Name

First

Last

D.O.B

Sex

Age

Marital Status

Profession

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Mobile Number

Diagnosis

Referred to us by

Welcome to Healing Harmony Homeopathy & More Clinic. Homeopathy, as a medicinal field, aims to look beyond the mere physical symptoms. It aims to correct the deeper inner disturbances. Unlike other systems of medicine, Homoeopathy does not look at the diseased person in parts, i.e. it does not give different medicines for headache and stomach-ache to the same person. Instead it gives one medicine for the whole individual. Also, no two persons are alike. Similarly, no two persons react alike in sickness. Though suffering from the same ailment, the symptoms of one person may differ completely from the symptoms of another. As a result, everything that sets apart the suffering individual from another person having the same complaint is studied and analyzed. It is thus holistic and individualistic in nature restoring man’s health in body, mind and soul.

A Homeopathic remedy is mainly selected based on the symptoms you (client / patient) give us. If we are to make a successful homeopathic remedy selection, we must know all the details of your sickness. We must also understand all the features that belong to you as an individual. This includes your reactions to various factors, your past and family history and your mental condition. All this information enables us for proper selection of the remedy.

In order to find out all about you, we shall be asking you many questions. Each one of these questions has a definite meaning and significance for us. You must be free and frank, give us complete and true information on each point. Please read each question carefully, think and then answer completely. Do not keep anything back. Remember, whatever you tell us will remain absolutely confidential.

Case Record

Your general health has been

Excellent
Good
Fair
Poor

What your energy level on a scale of 1-10? (increasing level)

Height

Weight

Have you had any of the tests?

Chest X-ray: when, why, and result?

Ultrasonography: when, why, and result?

Blood Tests: when, why, and result?

ECG: when, why, and result?

Tuberculosis Tests: when, why, and result?

Other tests: when, why, and result?

PREVIOUS DISEASES & DRUGS USED

Previous diseases / Past history

Mention any drugs, tonics, stimulants etc. That have been used by you at any time in life:

Have you used Homeopathy before? If so, who was your practitioner? Remedies taken? And their Results?

Family Information

Major diseases that your family members are suffering and cause of death:

Health of your Husband / Wife?

Number of children, their age & about their health?

Personal History

Did your mother have any problem during your pregnancy?

Was there any difficulty about your birth? Give details

Vaccinations & Inoculations: (Any reactions to them)

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

PHYSICAL GENERALS

How is the your appetite?

Hunger? Is it tolerable/intolerable

How is the your thirst?

What do you crave/desire/love to eat?

Any particular dislikes in food?

Does any food or drink cause any problem?

Do you have any problem regarding your stools?

Any problem about urine?

How much do you sweat?

Where and on what part does he/she sweat most and does it have any odor or does it stain?

Do you have any problems in the sexual sphere?

How is your sleep?

During sleep (any dribbling, grinding, snoring, talking etc.)

Dreams? Dreams are an expression of the unconscious and of our personality. They are therefore of great significance for remedy selection in homeopathy. Describe any dream that your child has shared with you - any repetitive dreams, any nightmare or particular kind of dreams he/she gets.

THERMALS

Reaction to Season: Like summer/winter/ rains/ fall/spring

Reaction to Fan, Covering, Heat/Cold, Bathing

FOR WOMEN

Menses: How are the periods: regular or irregular?

At what age did it start?

How long do they last?

Menstrual flow: Is there any change now in quantity, color, smell or consistency?

Any problems: Before Menses, During Menses, After Menses

Is there any white discharge?

Any itching, excoriation etc. due to discharge?

Any problems during menopause?

ANY COMPLAINTS ABOUT

Head:

EYES & Vision:

EARS & sense of hearing:

NOSE & sense of smell:

FACE & Facial expression:

MOUTH & sense of taste:

About LIPS, MOUTH, TONGUE:

TEETH, GUMS e.g. carious teeth m bleeding gums:

Any other problems

Mind

MIND It is now universally acknowledged 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. 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 makeup. Answer freely. Answer frankly. Answer completely. Describe yourself: Write anything that comes to your mind. Your likes/dislikes, strengths/weaknesses, incidences of life that have left impact on you, hobbies etc.

Any fears?

Any Axinites

How are you in school/ college/office/ house?

How is your anger?

What are you sensitive to?

What makes you cry?

How is your mood?

Your views/philosophies of life?

Any worries? Family/health/ finances/work/ relations

How will you react if someone harms/hurts you?

What makes you happy?

What makes you sad?

How is your memory?

Do you like company? Or like to remain alone?

In your opinion, which aspects of your mind and moods are not agreeable to you? In spite of your awareness and maturity, are you unable to change these aspects?

Give a clear cut picture of your situation in life and your relationship with each of your family members, friends and associates in work

If you want to convey any other details please provide here

Thank you for your patience & co-operation in filling up this case record. This will help us select the right homeopathic remedy for you. We wish to treat you better.

Phone Number

Email

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