Homoeopathy online consultation proforma

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1. Full Name *

2. Sex *

Male

Female

Obligatorisk

3. Age *

4. Marital status *

Single

Married

Widow

Divorced

5. Number of Children *

6. Occupation *

7. City & Country *

8. E - mail id *

9. Your present complaint *

( Describe in detail)

10. Recently have you faced any bad or sorrow incidents ? *

( like death in family and surroundings, sudden and shocking news etc.,)

11. Does your Meternal or Paternal grand parents have the same problem ? *

Yes

12. How do you like to be ? *

Alone

Need company

Obligatorisk

13. Any sleeping problems ? *

Yes

Övrigt:

Obligatorisk

14. Do you get any dreams? *

( Explain in detail what type of dreams, what do you get in dreams etc., )

15. Your desire towards food? *

( explain which type of foods you like, sweet / sour etc., level of hunger, normal / high / low )

16. What type of climate you like? *

Cold

Hot

17. Habbits *

Smoking

Drinking

Tea / Coffee

Chewing

Obligatorisk

18. How is your level of thirst ? *

( high, low, drinking water at frequent intervals, thirst less etc., explain in detail )

19. How is your bowel movement ? *

( Regular, Constipated.,explain in detail.......... )

20. Stool *

( Colour of stool, hard/soft etc., explain any history of Piles, Fistula, Fissures)

21. Urine *

( Colour, quantity, frquency explain in detail )

22. Any other complaint other than this ? *

23. Past medical history ? *

( explain past medical history like any surgeries, medical treatment taken or undergoing now, fevers, etc., )

24. Any other information you would like to tell ?

Explain

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