How to present your illness to a Homeopathic DR

Preliminary data:

1. NAME:
2. AGE:
3. EDUCATIONAL QUALIFICATION:
4. OCCUPATION:
5. MARITAL STATUS: SINGLE/MARRIED
6. SIBLINGS: BROTHERS/SISTERS
7. RELIGION/CASTE:
8. RESIDENCE/ADDRESS:
9. CONTACT TELEPHONE NUMBER:
10. E MAIL:

PRESENTING COMPLIANTS: (For which you are seeking immediate attention from the doctor. Onset (How did it start- sudden/gradual), duration (since how long), and progression of the complaints with details of treatment availed)

Important informations required from the patient for planning an effective treatment:

1. Diet: Vegetarian/Non Vegetarian/ Mixed.
2. Appetite/Hunger: Increased/ Normal/ Reduced.
3. Digestion: Good / Easy indigestion/ Flatulence (Gas)/ Acidity.
4. Food intake: More salty/ more spicy/ more pungent/More sweets/ Balanced (Normal).
5. Any food item which you like most:

6. Pattern of eating: Hurried eating / eating slowly.
7. Thirst: Increased/ reduced/Normal
: Preference to cold water/warm water.
: Quantity taken per day.
8. Motion: Frequency – How many times a day?
: Consistency- Hard/ Well formed (Normal)/loose
: Urgency : Present/ No urgency.
: Satisfaction: Satisfied/ not satisfied.
: First stool: After rising/ after tea or breakfast/ Irregular.
: Any discomfort or pain: Before/during/after stool
: Bleeding: Before/ during/after stool.

9. Urine : Frequency: How many times a day.
: Night – Always/ some times.
: Urgency: Present/ no urgency.
: Flow- free flow/ Interrupted/ has to wait for long before the flow starts
: Control – good / less / No control.
: Difficulty/ Pain – Present/ Absent.

10. Sleep : Duration ……….PM to ……AM.
: Character of sleep : light / deep/ disturbed.
: Quality of sleep : Refreshing / Unrefreshing.
: Sleep disturbance : Always/ Rarely.
: Sleep disturbance : beginning / later part / Cannot specify.
: Afternoon sleep : Yes/ No.
:Covering during sleep: doesn’t like any covering( blanket)/ likes to cover full/ likes to cover till neck/ wants thin blankets/wants thick blankets.
: Dreams : always / very rare.
: Dreams : remembered / unremembered.
: Dreams : Anxious/ frightful/ any other…………

11. Sexual function : Normal / Increased / decreased.
12. Menstrual function : : Cycles: regular/ irregular/ always early / always late.
: Duration of flow: ……….days.
: Flow: Normal / more / less.
: Clots: Present/ absent.
: Pain during periods : Severe / Moderate / No pain.
: Any complaints Before / during /after periods.
: White discharge : Present / with itching/ absent.

13. Perspiration / Sweating pattern : Part: all over / some parts (for e.g. palms/ head)…….
: Odor (smell): Yes / no.

14. Obstetric history : : No of pregnancies ……..
: Abortions ………
: Any complaints during and after pregnancy…………….

15. Developmental history ( for children) : Mode of birth: Normal/ caesarian / forceps/……..
: Sitting at ………months.
: Standing………..
: Talking/ speech………..
: Urine control……………..
: Breast feeding till…………months.
: Feeding problems (if any)……….
: Any significant illnesses in childhood………like measles, chickenpox, fits, behavioral problems.
: Attention and concentration in studies:……..
: Performance in school……………
: General nature….Shy/ extrovert/ restless….
: De worming done………….
: Vaccination history…………..
: Behavior- restless/mild/irritable/`stubborn or if any……

16. Physical appearance: Lean/ stocky/ obese.
17. Skin- excessively dry/ normal/……….
18. Nails: Any problem- easy breaking / growing inwards/ painful nails/ etc……………
19. Hair on head: Hair falling/ dandruff / early graying..
20. Allergic to any food items:

21. MIND / EMOTIONS: : Easy anger/ irritability
: Can suppress anger / cannot suppress anger.
: Impulsive
: Mild in nature / rarely gets angry.
: Perfectionist / wants everything to be done in a perfect manner.
: Easy depression.
: Anxiety prone.
: Hurried / slowness.
: Reserved / extrovert.
: Cosmopolitan
: Too many friends and company/ least friends.

22. Any Habits: smoking / alcohol / any other.

23. Past history and Family history ( mention any significant illness in the family)
: Father –
: Mother –
: Brothers –
: Sisters-
: Wife-
: Children-
: Self :

24. Any investigations done so far like Blood, urine, Xrays, Ultrasound scan, C T Scan, any other……….

Important Note:
1. Never ignore some peculiar symptoms thinking that it is irrevalent , a Homoeopathic doctor may need to know each and every symptom of the patients to plan a rational and logical treatment.
2. Kindly carry all the investigation files along with you for proper analysis of the case.