Therapies Case Record Form

Download offline (click here) or fill the below form online:

Please enable JavaScript in your browser to complete this form.

Name

First

Last

Sex

DOB

Age

Marital Status

Profession

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Phone No.

Diagnosis

Referred By:

Welcome to Healing Harmony Homeopathy & More Clinic.

We are glad you are taking the steps towards inner-work! We believe that man is an organic unity, it’s a beautiful union of the body, the mind and the soul and that man needs not only the treatment of the part that is sick. Hence our approach is multi-dimensional and we offer a range of holistic therapies including Yoga, Meditation, Diet, Zen Counselling and other healing techniques along with homeopathic treatment. There is also a lot of material for you to read and understand principles of holistic health and for each of these systems and how they work, please ask at reception and feel free to discuss with the clinic regarding any question(s) you may have. For more information visit www.healingharmony.in and www.karvaanretreat.com 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 is your energy level on a scale of 1-10? (Increasing scale)

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.

Any habits/addictions that are bothering you?

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 INFORMATIONS

Describe yourself: Write anything that comes to your mind. How will you describe your nature, your likes/dislikes, strengths/weaknesses, view of life, hobbies etc.

How is your mood in general?

What are your positive qualities and skills? What do you like about yourself? What qualities have helped you to succeed at overcoming difficulties in the past?

Any recent or past stress that is bothering you? (Financial/Relationship/Spiritual/Health/Career/Social/Grief-Bereavement)

Any fears or anxieties?

Do you experience any physical complaints while experiencing the anxiety?

What are things, situations you are sensitive to and how do you generally react?

How are your relationships? Any relationship that strains you? (Personal/Professional)

Your views/philosophies of life?

What are the things that make you happy (try writing atleast three)

What are the things that make you sad (try writing atleast three)

How was your childhood?

Describe your sleep pattern?

Any recurrent dreams?

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

What are your personal goals from our therapies/healing techniques?

And how motivated do you feel to work on things in therapy?

If you want to convey any other details please provide here:

Phone Number

Email

Login/Sign up

Therapies Case Record Form

Welcome to Healing Harmony Homeopathy & More Clinic.

CASE RECORD

PREVIOUS DISEASES & DRUGS USED

FAMILY INFORMATION

PERSONAL INFORMATIONS

Thank you for your patience & co-operation in filling up this case record. This will help us during our work together during the therapy sessions.

Navigation

Useful Links

Our Clinics