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HOMOEOPATHIC MEDICINE IS MAINLY SELECTED ON THE SYMPTOMS YOU GIVE US.

If we are to make a successful prescription, we must know all the details of your sickness. We must also understand all the features that belong to you as an individual. This includes your reactions to various factors, your past, your family history & your mental makeup.

In order to find all about you, we shall be asking you many questions. Questions have a definite meaning & significance for us. Even something that you may think useless & is not connected with your trouble, may be the most important factor in deciding the correct homoeopathic medicine. That is why you must be free & frank and give us the fullest possible information on each point. Please read each question carefully, think & if necessary, consult someone to answer completely. Do not keep anything back. Remember, whatever you tell us will remain absolutely confidential.

Form in English

Step 1 of 5

1) Main complain & other associated troubles. (& detailed history of the present illness, the onset & course with dates).
2)Past History: elicit whatever illness you had uptill now & what treatment was taken.
3)Family History: Mention illness suffered by your family members/ reason of death a)Father b) Grandfather (paternal) c)Mother d)Grandmother (paternal) e)Brother f)Grandfather (maternal) g)Sister h)Grand mother (maternal)
4)How is your appetite ? Describe your full day meal
5)Any complaints if you have to remain hungry for long? Do you feel hungry at any specific time of a day ?
6)How much water do you drink in a day? Any Specific likings in drinking such as Luke warm, cold or chilled ?
7)Any Special desires or cravings in food ?
8) Anything which you don’t like in food ?
9)Any food intolerances ?

10)When & how many times a day do you pass stool?
11)Do you have any problem about bowel movements? Do you have to strain for stool?
12) Do you have belching or passing flatus?
13)Any complaints about urination 14)Do you have any trouble before, during & after passing urine? 15) Frequency per day.
16)How much do you sweat? 17) Where & what part do you sweat most?
18)Is the sweat warm, cold, clammy, sticky, musty, greasy, stiffens the linen, etc? 19) What is the smell like? E.g. Foul, Pungent, Sour, Urinous

MIND SECTION (Answer freely, frankly, completely) Tell us about characteristics of your nature. Try to describe your mental qualities in detail.
Here some of the hints are given, fill up what is applicable to you.Tell me in brief about your life situation, like your family, study, job and your surrounding environment
Tell me about You and your qualities in detail
Do you get angry? On what matter do you lose your temper and how you express it ?
Is there anything which makes you anxious or bother you? How? And How do you deal with it
Describe your fear. (if any)
Do you feel any negative emotions like…..jealousy, suspiciousness, hatred, revengeful???
What hurts you emotionally?

Any Depression, Brooding…
Do you ever become suicidal? When?
Any unwanted thoughts any time? What are they?
Have you any imaginary sensations or fears?
How is your memory? If poor, for what things is it poor? E.g. Names, Places, Faces, What you have read, etc
Do you weep easily? What makes you weep? How do you feel after weeping?
How do you feel if someone offers sympathy & consolation?
What irritates you? What makes you angry?
Do you like to be in company? Or do you like to remain alone? How easily you make friends or mingle with people
DO you get affected by disorder & unclean surroundings?
What are the greatest grieves that you have gone through in your life?
What are the greatest joys that you have had in your life?
What activities you deeply like?
Are there any matters which you deeply dislike? In your opinion, which aspects of your moods & mind are not agreeable to you? In spite of your awareness & maturity, are you unable to change these aspects?
When you are free, what thoughts come to your mind? Are you worried or unhappy over any of these conditions? Describe in detail for each, if applicable. Personal Domestic Economical Social Any other condition
If asked for three desires or wishes in life, what will you ask for?

9) SLEEP And DREAMS Describe your posture in sleep On the back Side Abdomen Any other posture
Are you able to sleep in any position? Do you get any specific dreams ?

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