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Consultation Form


After the consultation form is filled by you, we would decide whether homeopathy can help you or not. If we feel homeopathy can give you relief, further treatment plan is discussed mutually which includes - medicines to be taken, duration involved, diet and regimen to be followed, payment modalities, etc. If you have any queries please feel free to contact us.



Fields marked with * are mandatory.

 
Name:*
Age:*


Birth Date:
Sex:*


Marital Status:


Occupation (Nature of Work):


Address:*

City:*

State:

Country:*

Zip/Pin code:

Telephone:
Residence

Office
Mobile:

Email:*

Present Complaints
 


Kindly mention about your complaints in your own words. Please describe fully the trouble, including its origin, subsequent development and effects of treatments that were received. In this description, please be certain to cover at least the following points:

 
  • Area of body affected and when
     
  • Sensations and pains experienced
     
  • Circumstances (physical & emotional that have brought on the trouble)
  •  
  • Conditions that increase the trouble
  •  
  • Conditions that reduce the trouble
  •  
  • All other accompanying troubles

  •  

     

    Personal History

     

    Your Habits


    How Much ?
    Smoking
    Alcohol
    Tea
    Coffee
    Sleeping Pills
    Laxatives/Purgatives
       
     
    Milestones of Life

    Teething, Trying to sit up, Walking, Talking, etc. (whether on time, delayed, early)




    History of Trauma
    etc.


    Past History

       

    Diseases suffered


    Approximate
    age


    Duration

    Whether you completely recovered

    Medicines & treatment taken  

    Any other particulars

    Family History

    Any history of Cancer, Diabetes, Arthritis, Tuberculosis, Epilepsy, Skin diseases, Asthma,
    CVA/Stroke, Hypertension, Kidney diseases, Liver diseases, etc.




    Appetite & Thirst
    How is your appetite?
    How much thirst do you have?


    Any change of taste in your mouth?



    What are the foods or drinks you like?


    What are the foods or drinks which make you worse?


    Stool

    Do you have any problems regarding your stools?





    Do you have belching or passing of gas?






    Urination & Urine

    Any problems regarding urination or urine?



    Sweat

    How much do you sweat?



    Do you perspire on the palms or soles?



    Any symptom relating to sweating?



    Cold / Cough


    Do you catch cold easily?




    Sexual Sphere

    Any problems relating to sex or sexual organs




    Miscellaneous


    What kind of weather are you most comfortable in?
    Are you particularly uncomfortable in any weather or climate?



    How is your tongue – clean or coated?


    What about tonsils, adenoids and polyps in nose?


    What about salivation?


    What about sleep?

    Do you like to be in open air or do you feel more comfortable in a closed room?

    Additional information if any

     
    Additional Queries for Female Patients

    Age at onset of periods (Menarche)?
    Periods? (Regular/Irregular)
    Yes No

    Physical symptoms preceding the onset of periods (E.g. heaviness/pain in the breasts, changes in moods, changes in appetite, changes in bowel habit, backache, pain in the legs, headaches, dreams etc.)?



    Duration and interval between periods (E.g. bleeding last for 3-5 days and the interval between periods is 27 days)?


    Are you using any contraceptive pills?

     

    Yes


    No

    Any discharge before/during/after periods?

    Before
       During After   

    Number of children and whether the deliveries were normal? Any post-delivery problems? Were the children breastfed or not? Any problems during the breastfeeding phase? Any abortions? Any complications after abortions?


    Age of onset of menopause


    Did the periods cease gradually or abruptly?


    Gradually


    Abruptly


    Have you had any operations done in the pelvic area?


    Yes

    No

    If yes, details
       


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