Dr. Prasanna Kumar K
B.H.M.S., M.D.(Hom), Consultant Homeopathic Physician
Phone
+91 9482741496
Email
info@doctorprasanna.com
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Preliminary data :
Name
(required)
Email
(valid email required)
Age
(required)
Educational qualification
Occupation
Marital status
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Single
Married
Siblings
Brothers
Sisters
Religion/caste
Residence/address
Contact telephone number
Presenting compliants
Planning an effective treatment
Diet
--Select--
Veg
Non-veg
Appetite/hunger
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increased
normal
reduced
Digestion
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good
easy indigestion
acidity
flatulence (gas)
Food intake
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more salty
more spicy
more pungent
more sweets
balanced (normal).
Any food item which you like most
Pattern of eating
--Select--
hurried eating
eating slowly
Thirst
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increased
reduced
normal
preference to
--Select--
cold water
warm water
quantity taken per day
Motion: frequency - how many times a day?
consistency
--Select--
hard
well formed (normal)
well formed (normal)
loose
urgency
--Select--
present
no urgency
satisfaction
--Select--
satisfied
not satisfied
first stool
--Select--
after rising
after tea or breakfast
irregular
any discomfort or pain
--Select--
before
during
after stool
bleeding
--Select--
before
during
after stool
Urine : frequency: how many times a day
night
--Select--
always
some times
urgency
--Select--
present
no urgency
flow
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free flow
interrupted
has to wait for long before the flow starts
control
--Select--
good
less
no control
difficulty/pain
--Select--
present
absent
Sleep : duration
character of sleep
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light
deep
disturbed
quality of sleep
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refreshing
unrefreshing
sleep disturbance
--Select--
always
rarely
sleep disturbance
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beginning
later part
cannot specify
afternoon sleep
--Select--
Yes
No
covering during sleep
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doesn’t like any covering( blanket)
likes to cover full
likes to cover till neck
wants thin blankets
wants thick blankets.
dreams
--Select--
always
very rare
dreams
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remembered
unremembered
dreams
anxious
--Select--
frightful
any other
Sexual function
--Select--
Normal
decreased
Increased
Menstrual function
cycles
--Select--
regular
irregular
always early
always late
duration of flow
flow
--Select--
normal
more
less
clots
--Select--
present
absent
pain during periods
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severe
moderate
no pain
any complaints
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before
during
after periods
white discharge
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present
with itching
absent
Perspiration / sweating pattern
part
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all over
some parts (for e.g. Palms/ head)
odor (smell)
--Select--
yes
no
Obstetric history
no of pregnancies
abortions
any complaints during and after pregnancy
Developmental history ( for children)
mode of birth
--Select--
normal
caesarian
forceps
sitting at
standing
talking/ speech
urine contro
breast feeding till
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
--Select--
shy
extrovert
restless
de worming done
vaccination history
Physical appearance
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lean
stocky
obese
Skin
--Select--
excessively dry
normal
18. Nails: any problem
--Select--
easy breaking
growing inwards
painful nails
Hair on head
--Select--
hair falling
dandruff
early graying
Allergic to any food items
Mind / emotions
--Select--
easy anger
irritability
--Select--
can suppress anger
cannot suppress anger
impulsive
--Select--
Yes
No
--Select--
mild in nature
rarely gets angry
--Select--
perfectionist
wants everything to be done in a perfect manner
easy depression
--Select--
Yes
No
anxiety prone
--Select--
Yes
No
--Select--
hurried
slowness
--Select--
reserved
extrovert
cosmopolitan
--Select--
Yes
No
--Select--
too many friends and company
least friends
Any habits
smoking
alcohol
any other
Mention any significant illness in the family
father
mother
brother
sister
wife
children
self
Any investigations done so far like blood, urine, xrays, ultrasound scan, c t scan, any other