Medical History for Homeopathic Treatment
In order to find the correct Homeopathic remedy a lot of information regarding the chief complaint, associated complaints and the nature of person needing treatment is required. The information supplied by you will help to find the right remedy therefore you are requested to provide all information however irrelevant it might seem to you, honestly and to the best of your knowledge. Full cooperation is requested and all information collected is kept strictly confidential.
Please write N/A for the question if it is not applicable.
Name *
Your answer
Address *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
Date of Birth *
MM
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DD
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YYYY
Sex *
Height *
Your answer
Weight *
Your answer
Marital status *
Religion *
Your answer
Diet *
Addictions *
Smoking /alcohol /tobacco/Tea /Coffee/any other specify daily consumptions
Your answer
Chief Complaint *
Describe fully what bothers you most in detail .Each complaint should be described fully. a. Right from its onset to its subsequent development, treatment taken so far and response to the treatment b. Areas affected: location sensation, direction of spread, sequence of events c. Conditions that bring on the trouble/aggravate it paying attention to physical as well as emotional factors d. Factors that increase the trouble/afford relief e. Any other ailments experienced at the same time as the chief complaint for example perspiration/nausea/gases/sleeplessness/headache/pain.
Your answer
About Yourself *
Give a physical description of self followed by perception of yourself with regards to your Emotional nature, Intellectual attainments and aspirations,Indicate to what extent you have been able to realize them. Give a picture of your life, relationships and friendships. Do you suffer from anticipatory anxiety? Are you careful/careless, optimistic/pessimistic, hurried /slow, mild/irritable? Anything else that you can think of please do make a note of it.
Your answer
Educational Qualifications *
Educational qualifications, current occupation with full description of responsibilities and job satisfaction. Current family setup with in detail pertaining to all family members, their ages, what they are doing, your relationship, responsibilities towards them, including those that have died stating their age/cause of death. Financial responsibilities /strains past present. Any issues /difficulties experienced at work/family setup/social setup. Your daily routine from time you wake up to the time you retire at night including your dietary consumptions during the day.
Your answer
Reaction to surroundings *
* Food desires/aversions-foods that do not suit * Apetite * Thirst * Perspiration * General environment: weather/temperature * Sleep and Dreams * Sex (including menstrual and obstetric history in women)
Your answer
Previous Illnesses *
Any illnesses/surgeries/ailments you have had in the past
Your answer
Current Medications and Allergies if any *
Please list all medications that you are taking specifying their dosages
Your answer
Skin complaints *
Warts /corns/keloids/pimples/itching/eczema anywhere on the body
Your answer
Family History *
Diabetes/Hypertension/Heart disease/Asthma /Epilepsy/other
Your answer
Enclosures *
Copies of any reports: bloodwork/Xray/MRI/CTscan/ECG /other
Your answer
FOR PEDIATRICS PATIENTS ONLY
Childhood complaints *
* Nocturnal Enuresis (bedwetting) * Pica (eating mud/plaster/chalk/other) * Thumb sucking/attachment to a particular toy/blanket * Drooling saliva * Appetite (increased/decreased) * Urine (offensive smell/burning) * Stool (loose stools/constipation hard stools) * Perspiration (excessive/smell/stains) * Feet/socks smell?
Your answer
Child’s Nature/Behavior *
(Preferably both parents should write their own description of the child) In your own words describe your child as best as you can his weaknesses his strengths, his fears, his likes /dislikes, anything that you can think of * Sensitivity to pain/noise, Better /worse consolation, timid/brave * Behavior towards animals, drops/breaks things/destructive * Any fears dark/ghosts/separation anxiety/thunder/other * Dependant/clingy/independent * Reaction when denied what he/she is asking for * Overactive, Craves attention, Restless, Angry, Mild
Your answer
Milestones *
Walking, talking, crawling Social interactions (Plays alone/with others, leader/follower, talkative/quiet, Plays with younger/older children/peers, Competitive/aggressive/shy, Reaction to strangers)
Your answer
Mother’s state during pregnancy *
Description of pregnancy/labour/childbirth Any complications/complaints (physical/emotional)
Your answer
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