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Dr Sarpal - Patient's Case Taking Form for Homeopathic Treatment
A CLASSIAL HOMEOPATHY approach to cure a Person in disease/complaints/sufferings.
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Pateint's Name
*
Your answer
Age
Your answer
Gender
Your answer
Contact Information
Residential Address / Contact number / email id (optional)
Your answer
Present Disease/Compalints
Please mention not just the major, but also your minor complaints , if any
Your answer
Please mention the details, if you already have any X-Ray,Ultrasound,Blood,Urine or any other test report .
You can also enclose the scanned copy of it at our id
drsarpal@gmail.com
Your answer
Past history of any Disease/Compalints
Mention the major as well as minor past complaints , if any
Your answer
Your Disease/Compalints occurs usually in which side of your body
Usually Left side
Usually Right side
Always Right side
Always Left side
Any side (not specific)
Other:
Family(Biological- Mother,Father,Brothers,Sisters,Grand Parents,Uncles,Aunts) History of any Disease/Complaints (This is to check the genetic character of your disease )
Diseases eg. diabetes,cancer,stones formation problem, kidney disorders,hydrocephalus, skin disorders, arthrites,infertility problem,depression etc
Your answer
Which weather you dislike more :
mark the options according to your body acceptance level to the environment
Hot
Cold
Rainy/Spring
Autumn
None
Other:
In your food you like more
Your favourite flavours,most of the time
salty
spicy
sweets
sour
oil/desee ghee
Other:
Do you like drinking plain (white color) Milk ?
Milk without any added flavors or health drinks supplements
yes , always
I hate Milk's smell
no
yes at times I like drinking plane milk
Other:
Do you like Non-Veg/Meat ?
yes, I love it
I don't find it tasty
Don't like it much, but have to eat it as it is the only option left
I don't eat non-veg
I use to eat a long time ago, but not now
Other:
Do you like Eggs
yes, I love it
I don't find it tasty
Don't like it much
I don't eat Egg
I use to eat a long time ago, but not now
Other:
Do you like Fish
yes, I love it
I don't find it tasty
Don't like it much
I don't eat Fish
I use to eat a long time ago, but not now
Other:
Do you like Raw Tomatoes
yes, I love them
No, I don't
Other:
Do You feel Thirsty ?
Yes
Yes in Excess
No
Never
I think I have normal thirst level
Other:
Your sweat secretion level is ?
Excess
Normal
Less
Other:
Your sweat secretions are more in which area/areas of your body ?
Your answer
Your general attitude is ?
Positve / Optimistic
Neagtive / Pessimistic
Mood swings
Normal
Extremely Practical
Other:
Do you have any Perfume/ Odours/Perol's smell etc ,Aggravation ?
Yes, always
Yes, sometimes
No
Other:
You get ameliorated//like most of the time in ?
Specially whenever you are in stress
In a close room
In an open air
Other:
You get angry -
Easily
Rarely
Other:
Whenever you get angry -
I don't talk to any one
I hurt myself
I physically hurt others
I throw away anything
My ears get red
My hands get red and burning
My face get Red
My whole body or any body part gives a burning sensation
I start crying
I seek support
I get rude to everone
I forget easily
I don't forget , rather I think smartly how to get out of the situation
I make in my mind , that when ever I will get chance , I will take the revenge, without anyone knowing my real intentions
Other:
Do you startle easily ?
Yes always, even from a minor sensations/touch/noise/voice
At times, not always
No
Other:
What do you often see in your dreams ?
Snakes
Dead persons
Dead Relatives
Romantic
I rarely see dreams
Bad events happening to you
Good events happening to you
Other:
What is your financial attitude ?
Spendthrift
Smart spending attitue
I do bargaining , if possible
If I don't have money , I will borrow , and then shop
I am miser
I like purchasing expensive brands
Other:
What is your Intelligence level ?
High
Above average
Average
Below average
Low
Other:
Your Nature most of the times
Extrovert
Introvert
Somewhere between extrovert and introvert
Depends with whom I am talking
Depends on my mood
I don't know, I get mood swings
I have a laughing nature, usually
I have a serious nature
Other:
Do you get sun aggravation , even in normal exposure to the sun ?
Yes
No
Use to get sometime ago ,but not now
Other:
Your sexual fantasies/desires/activities are-
Less
More
Process Slow
Process Fast
Normal
Other:
Your appetite tolerance level
If I am hungry , I can't tolerate , I need to eat something
I can tolerate for some time
I don't feel hungry
Even if I eat digestible food, my stomach gets upset frequently
Whatever I eat turns into gas inside
Other:
Do you have tight clothing aggravation ?
Yes
No
I have aggravation in neck ,whenever any cloth or object touches it
Other:
Your Nature most of the time -
Anxiety
Restless
Depress
Timid
Shy
Sad
Happy
Indifferent
Angery
Naughty
Sexually excited most of the times
Emotional / Sentimental
Revengful
Haughty
Cunning
Charming
Caring
Compassionate
Other:
Are you hard working person/ dilligent ?
Yes
No
I am workholic
Depends on the situation
Depends on my mood
Other:
Your lying position most of the time -
Left sided
Right sided
Lying on abdomen
Lying on Back
Lying on any random position, not specific
Other:
Do you like tea ?
Yes , a lot
No, not at all
At times
Other:
Do you like coffee ?
Yes , a lot
No, not at all
At times
Other:
Are you addicted to tobacco ?
Yes , a lot
No, not at all
Some times, I smoke/chew tobacco
I have a past addiction of tobacco , I left it now
Other:
Are you addicted to alcohol ?
Yes , a lot
No, not at all
I drink occasionally
I have a past history of alcohol abuse
Other:
Are you addicted to anything else ?
Your answer
If you want to tell anything else about yourself ?
Your answer
If possible send any photograph of the patient at our gmail id
drsarpal@gmail.com
Or mention any unique/unusal feature if you have any on your face / body
Your answer
Please mention any of your email id , so that we can further contact you
*
Your answer
Dr Sarpal +919837318170
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