Homoeopathy Case-Taking Form

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Home
About Us
Treatment
Organ Systems
Blog
Contact Us

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Patient Information

Street Address *

Apartment, suite, etc

City

State/Province

Country

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Chief Complaints

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Duration Of Symptoms *DaysWeeksMonthsYears

Onset *SuddenGradual

Aggravating Factors *Cold WeatherHeatHumidityEatingExertionStressMovementRestLying downSittingOTHERS

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Past Medical History

Surgeries *YesNo

Allergies *NoYes

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Any history of trauma or accidents? *NoYes

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Family History

Any hereditary diseases in family members? *DiabetesHeart DiseaseCancerMental IllnessNone

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Mind & Emotional State

Personality *IntrovertExtrovertMixed

Mental Stressors *WorkFamilyFinancialSocial

Emotional Reactions *AngerSadnessFearAnxiety

Fears & Phobias *HeightsDarknessDeathPublic Speaking

Memory & Concentration *GoodAveragePoor

Dreams *No DreamsRecurrent DreamsNightmares

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Sleep Patterns

Sleep Quality *GoodDisturbedInsomniaExcessive Sleep

Position Of Sleep *BackSideStomach

Dreams *PleasantDisturbingRecurring

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Appetite, Thirst & Food Preferences

Appetite *NormalIncreasedDecreased

Cravings *SweetsSpicySaltySourNone

Aversions *MilkSpicy FoodSweetsOthers

Thirst *LowModerateExcessive

Digestion Issues *BloatingAcidityConstipationDiarrhea

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General Sensitivities

Weather Preference *WarmColdNeutral

Perspiration *ExcessiveNormalScanty

Body Temperature TendencyFeels HotFeels ColdNeutral

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Menstrual & Reproductive History (For Women)

Menstrual Cycle *RegularIrregularMenopause

Flow *ScantyModerateHeavyClotting

Pain *No PainMildSevere

Pregnancy History *NormalMiscarriagesComplications

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Urinary & Stool Patterns

Urination Frequency *NormalFrequentLess Than Usual

Burning Urination *YesNo

Stool Consistency *NormalConstipationDiarrhea

Any Associated Symptoms *PainBleedingMucus

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Skin & Hair

Skin Condition *NormalDryOilyAcneEczema

Hair Loss *NoneMildSevere

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Lifestyle & Habits

Physical Activity *SedentaryModerateActive

Habits *SmokingAlcoholDrugsNone

Relaxation Practices *MeditationYogaOther

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Observations (By Homeopath)

Facial Expressions *NeutralAnxiousSadAngry

Tone Of Voice *NormalLoudSoftTrembling

Posture & Gestures *NormalStiffFidgetySlouched

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Our lives are often disrupted by health, relationships, and responsibilities, but under one roof, we offer solutions to restore harmony and support a healthy life.

Home
About Us
Treatment
Organ Systems
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Contact Us

Clinic Hours

Monday :12.00 – 5.00pm
Tuesday :12.00 – 05.00pm
Wednesday :12.00 – 05.00pm
Thursday :12.00 – 05.00pm
Friday :12.00 – 05.00pm
Saturday :12.00 – 05.00pm
Sunday : Closed

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