Welcome to Homeopathic       Online Consultancy


PATIENT PROFILE
1. NAME:
2. ADDRESS:
3. PHONE NO:
4. E-MAIL:
5. AGE:
6. SEX :                                 7.WEIGHT (in Kg/lbs):
8. HEIGHT (cms/Inches):
9. OCCUPATIONS:
10. ANY OCCUPATIONAL DISEASES:
11. MARITAL STATUS:
(Married, Un-Married, Divorced, Widowed)
12. CLIMATIC CONDITIONS OF YOUR AREA:
(Please mention the seasons, Temperature, Snow, Humidity, etc.)
13. PLEASE MENTION THE PREDOMINANT AND REPEATED EPIDEMICS OR INFECTIONS OR DISEASES IN YOUR LIVING AREA:
14. STATE CLEARLY THE PRESENT SUFFERINGS :
(State starting period of sickness & details of development of symptoms. Submit clinical reports.)

15.CHRONOLOGICAL ORDER : HEALTH & MEDICAL HISTORY FROM BIRTH
Illness Age Period of suffering Type of treatment Whether completely cured Any sufferings since then
16. FAMILY HEALTH HISTORY
Relation Alive or Dead Diseases & Age Period of suffering
Father
Mother
Brother
Sister
Grand Father
Grand Mother

17. MEDICAL INFORMATION:
Any poisonous animal bites and Vaccination for bites?
Mention vaccination profile, any side or after effects of vaccination
Any drug reactions
Mention your habits and addictions.
Specify your physical frame (obese/slender/lean). Mention the period or incidences of change in your physical frame
Please mention any sufferings from sexually transmitted diseases and details of treatment-period of suffering etc.

18. MENTION YOUR DESIRES OR LIKINGS AND AVERSIONS OR DISLIKING. IF SOME FOOD ITEMS DISAGREE MENTION THE EFFECTS.
FOOD ITEMS DESIRE AVERSION EFFECTS
Salt
Sweet
Sour and Lemonades.
Butter & Fats
Milk
Coffee and Tea
Mud-Chalk-Slate-Pencils etc.
Eggs-Meat-Shellfish-Crab-Prawns etc.
Spicy food
Onions
Potato
Raw vegetables
Cold foods, drinks, ice creams
Warm food-drinks
Beer, Wine etc
Pickles

19. FACTORS THAT MAKE WORSE OR BETTER YOU OR YOUR SUFFERING CONDITIONS.
                                 Example: No:1 Pain in Spinal Region - Better On Lying On Back
                                                  No:2 Burning Pain in Stomach better by Eating or Drinking Cold Water
FACTORS BETTER WORSE SPECIFY DETAILS
Hot weather (Summer)
Cold weather (Winter)
Rainy weather
Cloudy (Sunny or Spring)
Change of seasons
Thunder, Storm, Lightening
Warm bath
Cold bath
Sun bath or exposure to sun
Walking
Climbing stairs-Going up
Going downwards or down stairs
Lying on back
Lying on left side
Lying on right side
Lying on abdomen
Looking from high places
Hearing music
Pressure or Hard Pressure
Massage or Steaming
When angry
After weeping
After getting consolation
In crowd
In closed rooms/churches
When thinking of illness
Full moon/new moon
Morning
Evening
Night
Mid Night
Early hours of morning
When alone
When in friends
Near sea
Any other factors

20. FOR FEMALE:
Details of menstruation (Regular/Irregular/Delayed)
Nature of discharge
Any problems (before/during/after) the menstruation physical or mental symptoms)
Any gynic problems like fibroids/bulky uterus/ovarian cysts etc.,
Are you suffering from leucorrhoea-nature of discharge any sufferings accompanying with it excoriation, itching, etc.,)
Mention about sexual sphere- any problems before/during/after coition
Any problems with female organs

21. FOR MALE:
Mention about any problems with male organs like hydrocel/pain in testis etc.
Sexual sphere- mention about ejaculation nature/ errection/ sexual problems-any problems before/during/after coition.

22. MENTION CLEARLY ANY RELATED DISEASES OR COMPLAINTS.
VERTIGO
HEAD-Headaches/Hair problems/Eruptions on scalp etc.
EYES AND VISION- Eruptions in eyelids/vision problems etc.
EARS AND HEARING-Ear pain/Discharges/Eruptions in and around ear etc.
NOSE-Sense of smell/Polyps/Adenoids/Nasal Sinusitis etc.
FACE-Discoloration/Pimples/Swelling/Eruptions pains, etc.
MOUTH-Ulcers/Salivations etc.
TEETH & GUMS-Nature of Teeth/Boils/Bleeding of gums etc.
TONGUE-Taste/Eruptions/Color/Coating etc.
THROAT-Tonsils/Soreness etc.
CHEST-Pain in Rib Cage etc.
CARDIAC PROBLEMS-
Hypertension, Heart diseases, etc.
BLOOD CIRCULATION-
Rate and nature of Pulse etc.
LIVER-GAL BLADDER/SPLEEN
/PANCREATIC GLAND
STOMACH DISEASES-Gastric Ulcers/Pain/Vomiting/Nausea etc.
KIDNEYS-Hydro Nephrosis/Caliculea/Pain etc.
INTESTINES-Flatulence/Constipation/Pain etc.
RECTUM AND ANUS-Piles/Fishers/Moisture etc.
BLADDER-Urination Urgency/Pain/Infections etc.
URINE- Colour, Pus cells-Pain and Burning while Urination etc.

SKIN & DISEASES.
MENTION CLEARLY THE CONDITIONS WHICH MAKE WORSE OR BETTER THE PARTICULAR SUFFERINGS OR DISEASES.

23.YOUR BEHAVIOR AND MIND STUDY.
 In order to understand about your nature about your behaviour and mind. We need detailed infromation about you. As such we hint certain Natures of Mind for detailed and described answers. Your answers shall ensure on the following points: I) Causation (ii) Any sufferings before, during and after (iii) Abnormalities of Nature of Mind (iv) Etiology etc.,

Example:
Nature of Mind: IRRITABILITY : Are you Irritable? If You say Yes, Then answer on this lines.
(i) Causation : The causative matters , conditions and circumstances for getting irritation.
(ii) Sufferings before/during/after: Any sufferings due to the irritation during or after irritation like shivering, fainting, headaches etc.
(iii) Abnormality : Finding any abnormality in your nature of mind while comparing with others.
(iv) Etiology : Getting of this nature of mind like irritability since loss of finance, or disease or due to weariness etc.
NATURE OF MIND:
Anxious and Nervous. Describe.
Jealous. Describe.
Restless and Impatient. Describe.
Hurry mind or Hurried. Describe.
Fearful. Describe.
Sensitive. Describe.
Depressive mood. Describe.
Sad or Despair. Describe.
Brooding on painful or unwanted matters. Describe.
Sexual or erotic. Describe.
Impulsive & Emotional. Describe.
Weeping. Describe.
Fastidious or Cleanliness. Describe.
Quarrelsome. Describe.
Suicidal. Any attempts?
Kindful and Sympathetic. Describe.
Are you offend easily? Yes No
Are you Egoistic? Proud? Yes No
Are you Pessimistic? Yes No
Are you Censorian or Fault finder? Yes No
Are you Adamant or Obstinate? Yes No
Are you yield easily to others? Yes No
Do you like others company ? Yes No
Do you like loneliness? Yes No
Do you hate Consolation? Yes No
Do you feel better when others show sympathy on you ? Yes No
Are you Talkative? Yes No
Are you revengeful? Yes No
Are you Bashful? Yes No
Are you much religious? Yes No
Can you tolerate injustice against you or others? Yes No
Will you fight for others and shoulder responsibility? No
Are you selfish or self centered? Yes No

PLEASE STATE BRIEFLY ABOUT THE FOLLOWING ITEMS
About your Memory and Concentration.
About your Thoughts.
About any sufferrings from Delusions or Illusions.
AILMENTS FROM:
(i) Loss of Love.
(ii) Death of Relative or loved one.
(iii) Failures.
(iv) Hurt or Insults.
(v) Grief or Shocks.
(vi) Divorce.
(vii) Stopping of Habits or addictions.
What makes you happy?.
Any further information about your mental state.

24. SLEEP
Describe your sleep.
In which position you cannot sleep?
Any problems during sleep (Snoring/Walking/Talking/Grinding teeth/Salivation/Urination, etc.)
Do you generally cover blanket during sleep if so up to neck or head or what are the covering parts?. Do you keep feet outside the blanket?

25.DREAMS
Mention the dreams you frequently get.

      

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