Online Homeopathic Clinic

HOMOEOPATHIC QUESTIONNAIRE FOR PATIENT

Please fill in this questionnaire in as great detail as possible. Things that you might feel are "medically not relevant" can give important information, such as your habits, patterns of behaviors, moods etc. So please report such things fully. Include any strange feelings and sensations that you think might be important, even if they are not specifically asked for in the questionnaire. Such information might give helpful information about your individual reaction to the illness, and thus help us prescribe the best medication for your problem. Of particular importance are changes that you have noticed recently, in appetite, in desire or aversion for particular foods, in behaviors, sleep patterns, bowel habits, dreams etc, so please report any such details that you have noticed.

Questionnaire Form
Name:
Email id:
Mobile:
Age:
Sex:	Please selectMaleFemale
Marital Status:	Please selectSingleMarriedDivorced
Address:
Occupation/Education:
PRESENTING COMPLAINTS /CHIEF COMPLAINTS
1.What is the location/area of complian?
2.What is the sensation or discomfort that you have?
3.Describe the origin of the problem and how it started?
4.When does the complaint increase/decrease?
5.What time or period of the day or night you feel pain or discomfort? increase?
6. Present complaint for which you have contacted us (If more than one problem is there, then state them in chronological order of their appearance)
7. Was there any cause/causes for the start of your illness?(physical, mental or emotional)
ASSOCIATED COMPLAINTS
Any gastric complaints, dust allergy, any headache you get when exposed to sunlight or any other health wise problems you are suffering along with the above complaints?
PAST HISTORY
Any serious ilness for which you needed hospitalization or long term treatment?
DRUG HISTORY
Any previous treatment that is going on for the presenting complaint or any treatment for any other trouble?(Mention the name of the medicine if possible and its dosage)?
FAMILY HISTORY
Does anybody from your family members including your parents and grand parents have/had any health related problems like high/low blood presser, Dibetis, Arthritis, skin complaints, asthma, pneumonia, tuberculosis, cancer etc?
PERSONAL HISTORY
(a) How is your appetite?
(b) Is there a tendancy to indulge in particular kinds of foods (eg:sweet, sour foods, salty foods, etc.)
(c) Are you allergic or sensitive to any foods? foods, etc.)
(d) What kind of weather are you most comfortable in?(Summers, humid weather, winter)
(e) Are you particularly uncomfortable in any weather or climate?
(f) Do you sweat at all? If you do, where do you sweat noticeably?(Scalp, upper lip, under arms, back, chest, etc) Under what circumstances?(While eating, under tension, when you physically exert yourself etc.)
(g) In general do you like being out in the open air or do you feel more comfortable in closed room?
(h) How is the quality of your sleep most of the time? (Rested and refreshed, feel tired most mornings etc.)
(i) Any complaint during night/sleep? (Rested and refreshed, feel tired most mornings etc.)
(j)How many times per day you visit latrine or pass stools? Any problem during passing stools?
(k)How many times you pass urine per (day & night)? Any problem during passing urine?
(l)Any habits of smoking/chewing tobacco/drinks?
(m) Do you dream at all? If you do, do you remember them? What is the content? (eg:daily events, falling into space , running after a train , etc.)
(n) How is your bowel habit? (Regular, constipated, diarrhea etc.)
(o) How is your liquid intake?(Feel thirsty all the time, fairly normal etc)
(p) How would you describe yourself?(Amiable, loner, quite social, tendancy to be very picky about things like cleanliness and keeping appointments etc.)
(q) How do you react to stress and tension? (Tend to verbally expressive, tend to keep things to yourself and brood about them etc.)
ADDITIONAL QUESTIONS FOR FEMALE PATIENTS
1. Age at onset of menstrual periods?
2 .Periods?(Regular/Irregular)
3. Physical symptoms preceding the periods (eg:heaviness/pain in the breasts, changes in moods, changes appetite, changes in bowel habit, backache, pain in the legs, headachs, dreams etc.)?
4. Duration and intervals between periods (eg:bleeding last for 3-5 days and the intervals between periods is 27 days?
5. Are you using any contraceptive pills?
6. Any discharge before /during /after periods?
7. Number of children and wheather the deliveries were normal? Any post-delivery problems? Were the children breastfed or not? Any problems during the breastfeeding phase? Any Abortions? Any complications after abortions?
8. Age of onset of menopause?
9. Did the periods cease gradually or abruptly?
10. Have you had any operations done in the pelvic area?
TERMS AND CONDITIONS1. All cases taken up for treatment or consultation are studied in detail using special software. 2. The best quality of medicines is used for dispensing the medicines. The medicines if asked for will be delivered to the patient by courier. 3. Since the consultation or treatment will have to take place with out physical examination of the patient without actually seeing the patient’s past medical records investigation reports it is not possible to offer a 100% guarantee of cure. Note that we do not claim to cure each and every case, nor do we guarantee any magical cure. The homeopathic medicines are essentially free from side effects because of its simplicity 4. The information provided by the patient on this site is treated strictly as confidential and will not be disclosed to any company or individuals 5. The medicines will be sent to you (if you are from a country where we dispatch medicines) by registered postal services. It will be the patient’s responsibility to find out if homeopathy medicines could be imported to their country. We will provide the details of shipment for tracking purposes. Unfortunately we won't be able to process the refund if the medicines couldn’t be delivered to you.THINGS TO AVOID1. Coffee 2. Camphor or camphorated products including products containg eucalyptus and camphor oils. 3. Dental work, teeth cleaning, drilling anesthetics. 4. Electric blankets 5. Nicotine 6. Recreational drugs 7. Some conventional drugs (be sure to tell your homoeopath what you are taking)
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