HOMEOPATHIC CASE RECORD FORM

Name: Address: Home Tel: Marital Status: Occupation: Referred by: Work Tel: How Long: Insurance Provider: SINCE? CAUSES? Number of Children: Age: City: Cellular: Date of Birth: Postal Code: E-mail: Ages: Employer:

MAJOR COMPLAINTS IN ORDER OF IMPORTANCE FOR YOU?

WHAT MEDICATIONS ARE YOU CURRENTLY TAKING?

SINCE?

ANY ADVERSE EFFECTS?

CHECKMARK EACH OF THE FOLLOWING CONDITIONS YOU HAVE HAD: Abscesses Depressio Heart Mononucleos Rheumatic n Disease is Fever Alcoholis Diabetes Hepatitis Mumps Rubella m Allergies Emphyse Herpes Palsy Scarlet Fever ma Anemia Epilepsy Influenza Pelvic Sexual Abuse Problems Arthritis GallKidney Peritonitis Skin Disease Stones Disease Asthma Goitre Leukemia Pleurisy Strep Throat Cancer Gonorrhea Malaria Pneumonia Sinusitis Chicken Pox Cold Sores Gout Hay Fever Measles Miscarriage Parasites Prostatitis Sunstroke Stroke

Syphilis Tonsillitis Tuberculosis Typhoid Fever Venereal Warts Warts Whooping Cough Worms Yellow Fever

ANY OTHER MAJOR CONDITIONS?

SINCE?

COMPLICATIONS?

WHAT OPERATIONS HAVE YOU HAD?

WHEN?

COMPLICATIONS?

ACHES & PAINS?

WHERE?

SINCE WHEN?

ACHES & PAINS?

WHERE?

SINCE WHEN?

WHAT MAJOR INJURIES HAVE YOU HAD?

WHEN?

LONG-TERM EFFECTS?

WHAT VACCINATIONS HAVE YOU HAD?

WHEN?

ANY ADVERSE EFFECTS?

HOW MUCH OF THE FOLLOWING ARE YOU USING? Coffee: Tea: Alcohol: Tobacco: Recreational Drugs:

INDICATE WHICH OF THE FOLLOWING AILMENTS HAVE AFFECTED YOUR RELATIVES: Alcoholism Allergies Arthritis Asthma Cancer Depression Diabetes Epilepsy Gonorrhea Gout Hay Fever Heart Disease Insanity Paralysis Pneumonia WHO? Skin Disease Syphilis Tuberculosis

IF YES TO ANY OF THE ABOVE, PLEASE EXPLAIN: ANY OTHER MAJOR AILMENTS? ARE YOU PREGNANT OR TRYING TO CONCEIVE?

IN YOUR OWN WORDS PLEASE DESCRIBE YOUR NATURE?

ARE YOU CURRENTLY UNDER THE CARE OF ANY OTHER PHYSICIANS or PRACTITIONERS? Dr. For: Treatment: Dr. Dr. For: For: Treatment: Treatment:

PLEASE CIRCLE OR DRAW IN THE AREAS OF YOUR PAIN IF NECESSARY, USE BOTH DIAGRAMS TO HELP EXPLAIN THE HISTORY OF YOUR PROBLEM.

FAMILY HISTORY Give in detail if any of your blood-relatives i.e. parents, grandparents, aunts and uncles are suffering or have suffered from the following, Just mention yes in the appropriate box.. Parents 1. Allergies: Eczema Hay fever Sinusitis, Cold Allergic bronchitis Asthma Urticaria 2. Arthritis: Gout Rheumatoid arthritis Osteo-arthritis 3.Cancer/Malignancy: 4. Diabetes Mellitus: 5 .Hypertension: 6. Coronary Artery Disease, Angina: 7. Tuberculosis: 8. Gonorrhea, Syphilis or STD: 9. Psychiatric & Mental Disorders: 10. Schizophrenia: 11. Anxiety Neurosis, Depression 12. Any other sickness not mentioned above? Grandparents Aunts Uncles

PERSONAL HISTORY Kindly elaborate and mention habits, addictions like alcohol, smoking, tobacco etc. Appetite:

Cravings in food: Mention grades of preference +, ++ or +++. For example if you love sweets, mention + or ++ or +++ Sweets Salty food Sour things / pickles Seasoned and spicy Milk Fried and fats Eggs Any other cravings in food? Thirst: How is your thirst? Please mention the grade of thirst? If you are very thirsty, you may mention grades +, ++ or +++ Would you prefer cold / chilled water or drinks even in the height of winter? Yes / No How many cups of tea / coffee do you generally take in a day?

GENERALITIES State how you are affected by or how you react to the following: 1. Do you like to cover your head (or wear a cap) when you go out in the cold or when exposed to draft of cold air? 2. Warmth in general, warmth of bed or of room, external warmth like hot fomentation etc. 3. Weather: Dry, Cold wet, Rains, Cloudy, Thunderstorms, etc. 4. Lack of sleep

5. In what part of 24 hours do you feel the best or the worst? 6. Do your troubles tend to occur or become worse, periodically (e.g. Daily or alternate days, every week, yearly, during new or full moon etc.)

STOOL / BOWEL MOVEMENTS Fill details in appropriate boxes Yes / No tency: Do you regularly have a satisfactory bowel evacuation? How many times do you move the bowels? Consis Well formed hard yes / No Any pain, burning, Piles / Fissure / Fistula? Semi-formed Loose

Any straining required?

bleeding with stool?

Any urgency for stools (e.g. Do you have to run for stool first thing in the morning or immediately after eating?

URINE Questions Frequency, day and night Any burning during urination? Any smell (Odour) in the urine? Any difficulty in passage of urine? Answers

Do you have any incontinence while coughing or sneezing?

Any associated complaints with urination?

PERSPIRATION (SWEAT): Do you perspire a lot? Yes/no Any particular part of the body that you perspire more on? (Head, neck, chest, back, palms, sole etc...) Any strong / offensive odour associated (e.g. Sour smell) with the sweat? Does the perspiration stain the clothes?

MENSES: please fill it correctly (very important to fill this section) Questions Age of appearance of first period (Menarche) How are the periods? (regular or irregular) Answers

What is the duration of your period and how many days cycle? any odour, Colour) How is the flow? (scanty, heavy, clotted,

Any complaints before, after or associated with the periods. . Any heaviness or pain in breasts before menses? Any nodules in the breast? Any PMT (Pre-menstrual tension)? Do you have any complaints associated with, before or after menses? E.g. Moods, Headache, irritability, Anger, Weeping, Depression, Diarrhea or Constipation

MENOPAUSE: Age of menopause

Any associated complaints at the time of menopause e.g. Hot flushes, Palpitation, Anxiety, Depression etc

PREGNANCIES: How many times have you been pregnant? How many children do you have and their age? Did you have smooth pregnancies?

Did you take any medication during pregnancy? Did you have normal deliveries?

If you are pregnant or nursing a childInclude any of the following issues on the next page into the Timeline where appropriate. Be sure to elaborate on any item that requires more information on additional paper. Details are significant. AIDS/HIV Hyperthyroidism Abnormal Pap Smear Hypoglycemia (Low Blood Sugar) ADD (Attention Deficit Disorder) Hypotension (Low Blood Pressure) ADHD (Attention Deficit Hyperactive Disorder) Hypothyroidism Allergic Dermatitis IBS (Inflammatory Bowel Disorder) Allergic Reaction to Medication Impotence Allergic Rhinitis (Hay Fever) Influenza ALS (Lou Gehrig's) Irritability Anorexia/Bulimia Liver Disorders ASD (Autism Spectrum Disorder) Loss of Limb Aspergers Syndrome Lupus Asthma Malaria/Yellow Fever/Typhoid Athlete's Foot Measles Bipolar Disorder (Manic/Depressive) Meningitis Bloating/Gas (Chronic) Menses (Difficult/Heavy/Irregular) Bronchitis (Chronic) Mononucleosis Cancer Morgellon's Syndrome Chicken Pox Multiple Sclerosis Chlamydia Mumps Chronic Ear Infections Muscular Dystrophy Chronic Fatigue Syndrome Near Drowning Chronic Pain Osteoarthritis Chronic Sinusitis Parasites Constipation (Chronic) Parkinson's Syndrome Crohn's Disease PDD (Pervasive Developmental Disorder) Depression PMS (Premenstrual Syndrome) Diabetes Pneumonia Diabetes (Gestational) Pregnancy Problems Diarrhea (Chronic) Prostate Disease Dizziness/Syncope Psoriasis Down Syndrome Rheumatoid Arthritis Dry Eyes Rubella Eczema Scarlet Fever/Scarlatina/Fifth's Disease ED (Erectile Dysfunction) Seizures Emphysema Sensory Integration Disorders Epstein-Barre Virus Sjogren's Disease Fainting/Blackout Spinal or Disc Disorders Fever Blisters (Cold Sores) Sprains/Strains

Fibromyalgia Staph Infection/MRSA Fractures Strep Infection Fungal Disorders of the Skin Surgeries GERD (Esophageal Reflux Disease) Syphilis Glaucoma/Cataracts Toxemia of Pregnancy Gonorrhea Tuberculosis Growing Pains Unconsciousness Head Trauma UTI (Urinary Tract

Infection/Disorder) Heat Stroke Vaccine Reactions Hepatitis Vaginal Discharge/Itching/Irritation Herpes/Shingles Vision Disorders Hot Flashes (Menopausal) Whooping Cough Hyperlipidemia (High Cholesterol) Yeast Infections Hypertension (Gestational)) Other

SEXUAL SPHERE FOR MEN - Any sexual disturbance? Excessive desire or aversion to sex

etc.

Disability of performance, premature ejaculation Night emissions

Any history of sexual abuse, excessive masturbation Any complaints after intercourse? FOR WOMEN Any sexual disturbance? Desire / Aversion to coitus?

Any leucorrhoeal (white) discharge? Itching, burning or discomfort associated? menses? SLEEP: Do you sleep well? Any sense of bearing down at the time of

Any particular dream that is recalled and often repeated? (e.g. Frightening dreams of falling from a height, or

being pursued by some men, or dead people or relatives) Does any of your complaints get worse or better before, during or after sleep? e.g. Cough or asthma attack that wakes you up at night or migraine on waking in the morning. Hot flushes just as you begin to fall asleep.

PREVIOUS TREATMENT TAKEN Disease:

Medicine Prescribed:

Investigations:

Laboratory Tests

X-RAY, USG, Scans, MRI etc. others

If possible, please scan and send the reports for better understanding. Thank you for your patience and thoroughness in completing the above questions. The homeopath works with details of all sorts, to piece together the health puzzle unique to every individual. This information will help us to design an approach to begin working with you or your child as efficiently and effectively as possible. Patient or Lawful Representative Full Name: ____________________________________________________________________

Signed: __________________

Date: _____________________

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