Arya Homoeopathic Clinic

Homoeopathic Case Record Form

REGISTRATION NUMBER: ………………………...…. DATE:

………...………...……

NAME: …………………………….……………………………………………………………......………………………………...

AGE: …….….… Years GENDER: MALE / FEMALE / OTHER STATUS: S / M

/W/D

ADDRESS: ………………………………………………………………………………………………………………………………

………………………………….……………………………………………………………………………………………………………

MOBILE NO: …………………………………………... EMAIL ID: ………………………...……………………………

EDUCATION: …………………... OCCUPATION: ……………………………… VEG / NON-VEG /

EGGS

RELIGION: …………………………. CASTE: …………………. NATIONALITY:

……………………….…………

BLOOD GROUP: ………………… HEIGHT: ………….……... WEIGHT: ………...………… BMI:

…………….

DIAGNOSIS: ……………………………………………………………………………………………………………………………

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REFERRED TO US BY: …………………………………………………………………………………………………………...

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 CHIEF COMPLAINT

SR. NO LOCATION SENSATION MODALITIES CONCOMITANT

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 INVESTIGATION

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MEDICATION
SR NAME STRENGHT MORNING EVENING NIGHT
NO
1

3
 9

10

PHYSCIAL CHARACTERISTICS

APPEARANCE: Lean / Thin / Obese / Short / Tall / Upper body part emaciated

SIDE AFFECTION: Left / Left then right / Right / Right then left / left upper and right
lower / right upper and left lower / one sided / Pain goes to side lain on / Pain goes
to side not lain on.

HEAD: Recurrent eruption on glabella / Swelling of glabella / Wrinkled

HAIR: Excess Hair / Split Hair / Brittle / Dry / Hair Loss / Oily / Rough / Tangle / Curly

COLOR: Black / Brown / Golden / Grey or White / Red

FACE: Big head and small jaw / Inverted pyramid face

EYE: Swelling upper or lower eyelid /

SCLERA – Blue / Brown / Yellow

PUPILS: Pupil dilated with coppery hue / Cylindrical pupil / Eccentric pupils

NOSE: Dilated nostrils / Knobby nose

MOUTH: Cracked at angle of mouth

TONGUE: Elongated tongue / Elongated tongue with pointed tip / Tongue catches
b/w teeth

CRACK: Across / Anterior Part / Tip / Deep / Centre (Across) / Edges / All Direction /
Lengthwise / Down Median Line Mapped tongue / Bifid tongue

DISCOLORATION: Black / Blue / Brown / Dark / Dirty / Grey / Green / Pale / Purple /
Red / White / Yellow

TEETH: Caries / Difficult Dentition / Gap between teeth / Serrated or irregular teeth /
Yellow teeth

4
GUMS: Abscess / Aphthae / Atrophy / Bleeding / Boils

DISCOLORATION: Black / Blue / Brown / Pale / Purple / Red / White / Yellow

LIPS: Biting / Bleeding / Cracked / Dropping / Dryness / Acne / Boils / Inverted /

Licking / Peeling / Picking / Quivering / Retraction / Swelling / Thick / Thin /
Indented

DISCOLORATION: Black / Blue / Brown / Pale / Dark / Red / Yellow

NECK: Folds of skin on neck / Long slender neck / Short necked person

NAILS: Brittle / Biting / Broken / Fungus / Hang Nail / Haemorrhages / Hepatic lines
on nail / Ingrowth / Paronychia / Ribbed / Ridged / Rough / Serrated / Split / Thin nail
/ Transverse ridge on nails / Vertical ridge on nail / White Spot

SKIN

DISCOLORATION: Café-au-lait / Hairy moles / Moles / Ecchymosis / Yellow

ERUPTION: Acne / Boil / Condylomata / Corns / Cysts / Excrescences

GROWTH: Ganglion / Keloids / Nodules / Tophi / Tumours / Warts

EXTREMITIES

HAND: Acute carrying angle of hand

FINGERS: Thin, long, slender finger

HEELS: Crack heels

THERMAL

C5 C4H C3H2 C2H2 C2H3 CH4 H5

HOT PATIENT WITH TENDENCY TO CATCH

COLD
CHILLY PATIENT WITH TENDENCY TO

5
CATCH COLD

FACTORS AFFECTING YOU

FACTORS EFFECT FACTORS EFFECT

Morning Forenoon

Noon Afternoon

Evening Twilight

Night Midnight

Midnight Before Midnight After

Hot Temperature Hot Days

Heat & Cold Cold Night

Cold Thunderstorm
Temperature
Clear Weather Dry Weather
Foggy Weather Cloudy Weather
Humid Weather Cold Weather
Damp Weather Warm Weather
Storms Weather Seaside
Summer Season Spring
Monsoons Winter
Autumn Wind
Open Air Draft of Air
Breeze Fan
Open Air Closed Room
Air Conditioner Sun
Moonlight Hills

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New Moon Full Moon
Waxing Waning
Daily Same Hour
Alternate Day Weekly
Monthly Seasonal
Yearly
Tight Clothes Loose Clothes
Woolen
Noise Music
Change of Change of
Season Weather
Strong Odor Light
Dust Smoke
High Places Narrow Places
Covering Smoking
Bath Desire Bath Aversion
Bath Aggravation Bath Amelioration
Bath Cold Bath Tepid
Bath Warm Bath Hot
Riding in Bus /
Car
After Short Nap Loss of Sleep
Getting Feet Wet Working in Water
Massage Physical Exertion
Yoga Jogging
After Hair Cut Shaving
In A Crowd In A Closed Room

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GETTING WET /
COLD APPLICATION
GENERAL
/ WARMTH
APPLICATION /
COVERING OR
UNCOVERING
AGGRAVATION OR LOCAL
AMELIORATION

CHANGE OF WEATHER / TEMPERATURE / SEASONS

COLD TO HOT
(HEATED)
HOT TO COLD
(CHILLED)
DEVELOPMENTAL LANDMARKS AND PROBLEMS

Physical Mental
Development Development
Dentition Head Holding
Turning Prone Sitting
Crawling Standing
Walking Object Grasping
Hand to Hand Pincer Movement
Transfer
Remove Puts on
Clothes/Shoes Clothes/Shoes

SPEECH
BABBLING: ………………………….…………………..……… WORDS: ……………………………………………..………

SENTENCES: …………………………………..……… RETARDED/LISPING/STAMMERING:

……………………..

SOCIALIZING: …………………………………………………………………………………………………….………………….

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CONTROL
BLADDER D/N: ………………………….………………………. BOWEL:
………………………….…………………………

FEEDING
BREAST: ……………………………….………..……..… TOP DILUTION:
………………………………..………….……..

BOTTLE: ………………………………..…………..……….. SOLIDS: ………………………….……………………………….

FEEDING PROBLEM
COLIC: ……..……..…….….... UNDERFEEDING: ……..…….…..….….. OVERFEEDING:
……..…………….…..

REGURGITATION & VOMITING: …………. LOOSE STOOLS: .………..…. CONSTIPATION:

……..………

FAMILY HISTORY

Sr No Relation Age Illness Cause of

Death
1 Paternal grandfather
2 Paternal grandmother
3 Maternal grandfather
4 Maternal
grandmother
5 Father
6 Mother
7 Paternal uncle
8 Paternal uncle
9 Paternal uncle

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 10 Maternal uncle
11 Maternal uncle
12 Maternal uncle
13 Maternal aunty
14 Maternal aunty
15 Maternal aunty
16 Sibling -
17 Sibling -
18 Sibling -
19 Sibling -
20 Sibling -
21 Sibling -

Sr. Children Gender/Age Illness Residence

No
1
2
3
4
5
6
DIGESTION – APPETITE – THIRST

How is your appetite? When are you hungry?

……………………………………………………………………….

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What happens if you have to remain hungry for long? Do you have a habit of eating

fast?

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……………………………………………………………………………………………………………………………………………….

How much thirst do you have?

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How frequently do you drink and how much?

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CRAVING & AVERSION

Alcohol / Almonds / Apples / Bananas / Biscuit / Bitter / Bread / Brinjal / Butter /

Buttermilk / Cabbage / Carbonated drinks / Carrots / Cheese / Chicken / Chocolate /

Coffee / Cold Food - Drinks / Cream / Crispy - Crunchy food / Cucumbers / Curd /

Dairy products / Delicacies / Egg / Farinaceous / Fat & Rich Food / Fish / Fried /

Frozen / Fruits / Garlic / Honey / Hot Food-Drinks / Ice Cream / Indigestible / Juice /

Lemon / Lemonade / Lentils / Meat / Milk / Nuts / Okra / Olive / Onion / Oranges /

Oysters / Pani-Puri / Pasta / Pastry / Pav-Bhaji / Pepper / Pickle / Pizza / Pork /

Potato / Pungent / Rice / Salad / Salt / Samosa / Shellfish / Smoked Things / Soup /

Sour / Spicy / Spinach / Starch / Sugar / Sweets / Tea / Tobacco / Tomatoes / Vada-

Pav / Vegetables / Vinegar / Warm Food - Drinks

ELIMINATIONS
STOOL
Do you have any problem regarding your stools? When and how many times a day do
you pass stools? Are you satisfied after passing stools?

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…………………………………………………………………

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When is it urgent? ………………………………………………………………………………………………………………….

Do you have to strain for stool? Even if soft?

…………………………………………………………………………..

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URINE
Any problem in urination? ……………………………………………………………………………………………………..

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Smell: …………………………………………………….……. Colour: …………………………….…………………….………

Control: …………………………………………………..…. Stream: ………..……….…………………………….………….

Any difficulty in the flow? Slow to start, interrupted, feeble, dribbling, etc.?
……………………………

……………………………………………………………………………………………………………………………………………….

Does the desire to pass urine come on at any particular time, or from any known
cause?

……………………………………………………………………………………………………………………………………………….

Have you ever had any blow or injury in this region (lower abdomen)?
……………………………………

PRESPIRATION
Where do you sweat the most?
………………………………………………………………………………………………

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Does it stain the clothes? What is the
colour? ………………………………………………………………………..

Does the sweat smell? What is the kind of smell?

……………………………………………………………………

SLEEP

POSITION: …………………………………….….………… DURATION:

………………………..……………………………

Are you uncomfortable in any position?

…………………………………………………………………………………

CHARACTER: Light / Catnap / Deep / Disturbed / Unrefreshing / Poor / Siesta

During sleep do you grind / snore / dribble saliva / sweat / keep mouth open / walk /

talk / moan / weep / become restless / wake up with a jerk, etc.?

How much do you cover / uncover any parts?

………………………………………………………………………..

State when and under what circumstances you are abnormally drowsy or sleepy.

………………………………………………………………………………………………………………………………………………

What causes the sleeplessness?

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How do you feel when first awaking and on first arising in the morning?

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How do you feel after a short nap?

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DREAMS

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MENSTRUAL FUNCTION

MENARCHE – Early / Late: …………… MENOPAUSE – Early / Late: ……………. L.M.P:

…………...…….
MENSES – Regular / Irregular / Continuous / Intermittent / Early / Late
CYCLE: ……………......…… Days DURATION: ………...…...…… Days FLOW:
………………...……
COLOR: Black / Brown / Dark Red / Pale / Pink
CLOTS: ……………..........…… CONSISTENCY: ……………..........…… ODOR:
…………….…......……
STAINS: ………………………………………………………………………………………………………………………………….
C BEFORE
O
N
C BEGINNING
O
M
I DURING
T
A
N AFTER
T
S

LEUCORHOEA: FROM EXERTION………………..…….………….. WITH DEBILITY

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………………………………..
ONSET: …………………………………. DURATION:
……………………………………………………………………………
CHARACTER: ………………..…….……… ODOR: ……………...……….……… COLOUR:
………..……………………
OCCURRENCE: ……………………………………………………………………………………………………………………….
COITION AFTER: ……………………………………….………. MENSES: Before / Beginning / During /
After
WHAT COLOUR DOES IT STAIN THE NAPKIN OR CLOTHING?
…………………………………………………..
WHAT OTHER COMPLAINTS ALWAYS COME ON OR ARE WORSE WHEN THE
LEUCORRHOEA COMES ON OR IS WORSE?
……………………………………………………………………………………………………..

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DOES IT CORRODE THE CLOTHING?

……………………………………………………………………………………….

MAMMAE: …………………………………………………………………………………………………………………………….

NIPPLE: ………………………………………………………………………………………………………………………………….

SEXUAL FUNCTION

Have you or had any eruptions, soreness, warts, etc on or around your genitals?

…………………………………………………………………………….…………………………………………………………………

DESIRE: Normal / Increase / Decrease / Suppressed / Absent

HOW DO YOU FEEL AFTER SEXUAL INTERCOURSE?

………………………………………………………………..

MASTURBATION: Frequency …….……… Nocturnal Emission ……...…… Prostatorrhea

…..……..….

COITION: Frequent …………..……….…..… During ……………….……….…… After

………....................……

ERECTION: Normal / Incomplete / Absent / Painful

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EJACULATION: Normal / Premature / Involuntary / Absent / Retarded / Painful

STATE ANY AFFECTION OF THE TESTICLE:

……………………………………………………………………………….

VAGINA: LUBRICATION - Normal / Decrease / Increase ORGASM: Normal /

Decrease / Absent

VAGINA: Dryness / Spasm / Numbness / Cracks

WHICH METHOD DO YOU USE FOR FAMILY PLANNING (CONTRACEPTION)?

………………………….

ANY RECURRENT INFECTIONS OF THE GENITAL ORGANS?

………………………..……………………………

HAVE YOU EVER BEEN INJURED IN THE PELVIS REGION?

………………….…………………………………….

DID YOU SUFFER FROM ANY SEXUALLY TRANSMITTED DISEASE, LIKE SYPHILIS,
GONORRHEA, HERPES, H.I.V., ETC.?
……………………………………………………………………………………………………………..

PATIENT’S / MOTHER OBSTETRIC HISTORY

GRAVIDA PARA ABORTION LIVING DEAD

ABORTION: NATURAL ………..…. INDUCED ………..…. HABITUAL ……….…. THREATENED

…….…….
ANTENATAL PERIOD: AGE AT THE TIME OF CONCEPTION:
…………………………………………………….
PLANNED / UNPLANNED (UNWANTED) PREGNANCY…………………….….. DESIRE FOR

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M/F CHILD

ANTENATAL HISTORY
WEIGHT GAIN ………………..…….. MORNING SICKNESS ……….…..…..…….. PYROSIS
……………….……..

PICA …………………..…….. BACKACHE ……….………..……….. FOETAL MOVEMENT

…………………………..

OEDEMA ………………….. BLOOD PRESSURE ………………….. PROTIENUREA …………………..

CONVULSION …………….…….. SKIN PIGMENTATION ……….………….. PILES …………………..
VARICOSE VEIN …………………..…….. HEMOPTYSIS …………………..…….. A.P.H
…………………..……. INFECTION …………..………..…….….. TORCH ……………….………..…….. OTHERS
………………………..……..

MENTAL STATE DURING PREGNANCY:

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DRUGS: ………………………………………………………………………………………………………………………………….

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LABOUR
UTERINE INERTIA …………………….….………………….…….. RIGID OS
………………...………..…………………..
PPH …………………….….………..……..……….…….. PLACENTA
…………………….…….….………………….……..
DELIVERY: FTND / Forceps Vacuum Suction / Caesar / Version / Induced /
Premature / Postmature
BIRTH WEIGHT ……..……….. NEONATAL PROBLEMS: Asphyxia / Jaundice / Sepsis /
Cord / Infection / Bleeding

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POST-PARTUM
LOCHIA ………………..………….….. SEPSIS …………..…….….……….... LACTATION
…….………….….………..
MENTAL STATE DURING POST PARTUM:
……………………………………………………………………………….
……………………………………………………………………………………………………………………………………………….
MOTHER FOETUS BOND: Attached / Ambivalent / Rejection / Delayed (Isolation)

PARTICULARS OF EACH PREGNANCY

Description Mother’s problems Birth weight Children’s problem

ADDICTIONS

ADDICTIONS HOW MUCH?

Alcohol or any other Beverages
Any Drug Substances
Cannabis
Cocaine
Internet
Laxatives/Purgatives
LSD
Marijuana
Nail Biting
Paan
Pornography
Shopping
Sleeping Pills
Smoking
Snuff
Supari

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 Tea/Coffee
Tobacco
THE MENTAL STATE

AILMENTS FROM / CAUSATIVE

FACTOR

AILMENT FROMS: Abandonment / Abuse by Relatives / Abusive Husband / Abusive

Parents / After Anger / Alcoholic Father / Anger from Neglected Childhood /
Anticipation / Anxiety / Bad News / Bereavement / Betrayal / Business Failure /
Control / Controlled / Criticism / Deceived / Disappointment in love / Discords
between Chief & Subordinate / Discords, Between Friends / Discords, between
Parents & Children / Displeasure / Domination / Embarrassment / Failure / Fear /
Fright / Grief / Grudges / Guilt / Honour (Wounded) / Humiliation / Jealousy / Joy /
Loss of Familiar Ground / Loss of Wealth, Relationship / Mothers Affection Absent /
Neglect and Mal-Treatment in Childhood / Not Cared / Parental Violence / Pride /
Prolonged History / Protection / Punishment / Quarrel / Rejection / Reproaches /
Reserved / Restrictions / Reverses / Ridicule / Rudeness / Rudeness, of / Scorned /
Sexual / Shame / Stress / Stress / Stress, of Public Performance / Terrors (Of War,
violence) / Terrors of / Tragedies / Traumatic / Unfulfillment / Unhappiness
(Prolonged) / Unhappy / Unloved / Unwanted / Violence / Worry / Wounded

WILL

ANGER: cares with / cheerfulness with / anxiety with / fear or fright with / grief with /
indignation with / answer with obliged to / consolation agg / contradiction / guilt
with / impatience with / jealousy with / love disappointment from / menses before /
menses during / mistake about his / offended when / refused when / repentance
with / reproached when / taciturn with / trifles / when not understood / oneself /
sadness with / silent / suppressed / violent / vehemence with.

What bodily symptoms do you develop when angry? E.g. trembling, sweating, etc.

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…………………………………………………………………………………………………………………………………..……………
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ANXIETY: Alone When / Anger During / Anticipation / Approached of People On /

Bed Driving Out Of / Climacteric / Closing Eyes On / Clothes Must Loosen / Coffee
Agg / Coldness With / Company / Cough / Cruelties / Dark In / Driving Place to Place
/ Excitement / Faintness with / Fasting agg / Fear with / Flatulence with / Flushes of
heat with / Fright after / Headache with / Heat complaints with / Hurry with / Menses
before / Menses during / Menses after / Motion agg or amel / Nausea with / Pain
with / Palpitation with / Perspiration with / Weakness with.

FEAR: Accident / Alone of being / Animals / Appearing in public / Approaching of

others-vehicle / Arrested of being / Authority / Bad news / Bees / Betrayed of being /
Birds / Brilliant objects / Business failure / Cancer / Cat / Closed place /
Cockroaches / Crossing bridge-place -street / Crowd in / Cruelties / Danger
impending / Dark / Death of / Going to dentist / Disease impending / Doctors / Dog /
Downward motion / Duty-taking / Failure / Falling / Forsaken / Future / Ghost /
Happen something / High places / Hurt of being / Infection / Injection / Insanity /
Killed of being / Opposite sex / Judge of being / Shadow / Misfortune / Sin /
Laughed and mocked being / Snake / Noise / Solitude / Observed / Spider / Poison /
Stranger / Pitied / Suffering / Poverty / Suffocation / Punishment / Suicide / Quarrel
/ Supernatural power / Rain / Superstitious / Rat/mice / Terror / Rejection /
Thunderstorm / Reproached / Robber / Salvation / Self-control losing / Touched of
being / Responsibility / Undertaking new things / Riding in a car / Work

GRIEF: Ailments From / Anger With / Business Thinking Of / Cry Cannot / Deception
From / Dullness / Ennui (Boredom) / Fear / Financial Loss From / Forgetfulness /
Headache With / Insult or Offenses After / Jealousy With / Love Disappointment
From / Past Events / Prolonged and Unresolved / Sadness / Silent / Vexation.

What are the greatest grieves that you have gone through in your life?
……………..………………

………………………………………………………………………………………………………….……………………………………

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HATES: Family / Men / Offended / Revengeful / Unmoved by apologies / Who do not
agree with her / Women

……………………………………………………………………………………………………………………………………………….

INDIFFERENCE: Agreeable Things To / Business / Company / Complain Does Not /

Duties / Ennui With / Excitement / Everything / Family / Fever During / Happiness /
Health / Irritability / Joy / Life / Loved Ones / Masturbation From / Menses During /
Mental Exertion After / Morose / Personal Appearance About / Pleasure / Relations/
Sadness With / Sleepiness With / Sleeplessness With / Study / Sufferings / Taciturn
To / Weakness With / Weariness With / Welfare Of Others / Work Aversion To.

IRIITABILITY: Alone / Anger / Anxiety / Coition / Company / Consolation /

Contradiction / Disappointment / disturbance from slightest / excitement / hunger /
indigestion from / Menses before / Menses during / Menses after / Music / Noise /
Offenses from / Pain from / Sadness from / Sleepiness with / Sleeplessness with /
Weakness / Taciturn

LOQUACITY: Anger with / Excited when / Fever / Headache during / Menses /

Religious / Unimportant

What activities you deeply like?

……………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………….

What are the greatest joys that you have had in your life?
…………………………………………………

……………………………………………………………………………………………………………………………………………….

SADNESS: Afternoon / Alone when / Anger with / Bad news after / Brooding with /
Causeless / Cloudy weather / Coition after / Consolation makes it better /
Consolation makes it worse / Darkness / Delivery after / Despair with /
Disappointment from / Disappointment in love from / Disease about / Domestic
works / Dwelling on one’s condition / Enjoy it / Evening / Grief after / Harsh words /
Health about / Humiliation after / Hunger with / Impotency with / Insult from /
Jealousy with / Losing the affection of friends / Masturbation from / Menopause
during / Menses after / Menses before / Menses during / Misfortune / Money losing

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/ Morning / Mortification/ Music makes it better / Music makes it worse / Night /
Noise / Pain from / Palpitation with / Past event about / Position loss after / Rainy
weather / Reverse of fortune from / Rudeness / Sighing with / Sleepiness with /
Sleeplessness with / Suicidal thought/attempt with / Suppressed sexual desire /
Taciturn / Thunderstorm makes it better / Vexation after / Weeping makes it better /
Weeping makes it worse / When others are happy

WEEPING: After humiliation / After mortification / Afternoon / Anger after / Anger

during / Better by consolation / Cannot weep though sad / Causeless / Cloudy
weather / Contradiction from / Easily / Evening / From admonition / From despair /
From forsaken feeling / From offense / Joy from / Menopause / Menses after /
Menses before / Menses during / Morning / Music from / Night / Remonstrated /
Reprimand / Reproach / Seeing others hurt / Silent weeping / Sleep during / Slightest
emotion / Thanked when / Thinking about future / Thinking of past event /
Ungrateful / Vexation / When alone / When pitied / With headache / With irritation /
With pain / With prolonged fright / Worse by consolation.

How you do you feel after weeping? …………………………………………………………………………………..

What are your three wishes?

1
2
3

EMOTION

EMOTION: Absent Minded / Abusive / Active & Energetic / Angry / Anxiety & Worry /
Company / Consolation (Welcomes or Hates) / Deceitful / Devious / Egotism /
Extrovert / Forsaken / Greedy / Happy / Hatred / Hurried / Impatient / Impetuous /
Indecisive / Indifferent / Introvert / Irritable / Jealousy / Malicious / Cruel /
Melancholic or Depressed / Methodical / Mild / Moans or Sulks / Morose / Music
(Loves / Hates) / Neat/clean / Negative (Pessimistic) / Obsessive (please detail) /

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Organized / Positive (Optimistic) / Procrastinate / Punctual / Quarrelsome / Restless
/ Sentimental or Weepy / Shy / Slow, sluggish or Indolent / Sluggish / Sociable /
Stubborn / Suicidal Thoughts / Suspicious / Sympathetic / Talkative / Timid / Untidy
/ unclean / Violent / Destructive / Workaholic / Yielding

Please reveal 6 emotional characters from above which most strongly implies /
represents you?

SENSITIVENESS: Arts / Colours / Cruelties / Crying of children / Disorder / Emotion /

Flower / Head pain during / Laughed at being / Light / Menopause during / Menses
before / Menses during / Moral impression / Music / Noise / Odour / Opinion of
others / Pain / Presence of other people / Quarrel / Reading / Reprimand /
Reproaches / Rhythm / Rudeness / Sacred (bhajan) music Sad stories / Touch

Generally, how would describe yourself as, slow / medium / fast pace?
……………………………….

……………………………………………………………………………………………………………………………………………….

INTELLECTUAL

BEHAVIOUR: Aggressive / Destructive / Extravagant / Fastidious / Grimacing /

Homesick / Hurry / Impatient / Impetuous / Inactive / Inconsistent / Jesting / Lewd /
Obstinate / Perfectionist / Quarrelsome / Reserved / Shy / Violent / Vivacious /
Weepy

How is your memory? For what is it poor? E.g. names, places, faces, what you have
read, etc.

……………………………………………………………………………………….……………………..………….………………………
…………………………………………………………………………………………………………………………………………….

SPEECH: Averse / Censorious / Confused / Cursing / Excessive / Foolish / Hasty /

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Incoherent / Irrelevant / Loud / Lying / Monosyllabic / Nonsense / Obscene /
Prattling / Refuses / Repetitive / Rude / Singing / Slow / Slandering / Slurred /
Stammer / Wandering

What activities you deeply like? …………………………………………………………………………………………..

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How seriously are you affected by disorder and uncleanliness in your surrounding?

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How is your memory? For what is it poor? E.g. names, places, faces, what you have
read, etc.
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CHILDHOOD HISTORY

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AFTER MARRIAGE

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PHYSICAL EXAMINATION

TEMPERATURE: ………………… PULSE: ……………… BLOOD PRESSURE: ……………… SpO2:

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CRAMPS: ………………… CLUBBING: ………………… CYNOSIS: …………………… PALLOR:

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JAUNDICE: …………………… OEDEMA: ………………….……… EYE:

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THROAT: ……………………………………….………..…… NOSE:

………………………………...…………….…………… EAR: …………………………………..…….……HIRSUTISM:
……………….. GYNECOMASTIA: …………………..

LYMPH NODE (Cervical / Axillary / Supraclavicular / Inguinal):

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ABDOMEN

Palmar Erythema / Spider Nevi / Parotid Swelling / Flapping Tremor

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Shape of Abdomen: ………………... Umbilicus: ……………... Abdominal Movements:
………………... Pulsations: ……………... Dilated Veins: ………………... Hernia: ……………...
Tenderness: ………………... Fluid Thrill: ………………... Peristalsis: ……………... Rub: ……………...
Bruit: ………………... Puddles Sign: ………………... Abdominal Girth: …………………...

RESPIRATORY SYSTEM

CUTIS VULGARIS / SCROFULODERMA / ALAE NASI

SHAPE OF CHEST: RR: ………. Auscultation: ………...……...……… Trail Sign

Peak Expiratory Flow: …………………… Movement of Chest: ……………………...

CARDIOVASCULAR SYSTEM

Xanthomas / Xanthelasma / Corrigans Sign / De Musset’s Sign / Quincke’s Sign

CENTRAL NERVOUS SYSTEM

SPINE: Scoliosis / Kyphosis / Lordosis FOOT: Flat foot / Pes Cavus

Rinne’s Test: ……………...…………… Weber’s Test: ……….…………....…… Gag

Reflex: …………….………

Romberg’s Test: ………………… Tandem Walking: ………….………… Finger

Nose Test: ……………………

Finger to Finger Test: …………………… Knee Heel Test: ……………………

ANALYSIS OF THE CASE

AILMENTS FROM / CAUSATIVE FACTOR

WILL EMOTION INTELLECT

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 SEXAUL SYMPTOMS GENERALS

CHARACTERISTIC PATICULAR PATHOLOGY

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