Homoeopathic Case Record Form.

C O N FI D ENTIAL

Date:

Name: ________________________________________________________
(Begin with Surname)

Date of Birth: Age:

Sex: Male / Female

Address:

Telephone (R):

Mobile:

E-mail:

Religion: Diet: Veg. / Non veg.

Marital status: Single / Married / divorced / widowed.

Education:

Occupation (Nature of work):

Address of work place:

Telephone (W):

E-mail:

Nationality: Language spoken:

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Referred to us by:

Please read this first before filling the form

The aim of case form is to give our homoeopathic consultants a fair idea of you as an individual.
Please read the following instructions carefully before proceeding to fill the form.

All our efforts will be concentrated towards selecting the best possible medicine for you.
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 and family history and your mental
makeup. In order to find out all about you, we shall be asking you many questions. Each one of
these questions has a definite meaning and significance for us. Even something that you may
think is not connected with your trouble may be the most important factor in deciding the correct
homoeopathic medicine. So please feel frank in giving information.
Read each question carefully, think, and if necessary, consult someone close to you and then
answer completely.

To tell or write to a homoeopathic physician, " I have a headache, eruptions, or a cough is not
enough. If you inform him that I have headaches with sharp shooting pains, especially in the left
side of the head, more so at night when going to sleep. The pains are much better when the head
is tied up and he/she cannot tolerate fan at all. I am irritated with the pain so much so that the
least noise or things not in their place makes the headache worse, till I can see that things are
back in their original place."
This kind of a feedback is more certain to help your homeopath, in understanding your
personality type and hence your remedy better.

We reserve the right to use this information provided by you for our in-house research or
statistical purpose.

‘The centre’ also aims at providing advanced clinical training to homoeopathic students /
practitioners. To achieve this, the academy conducts lectures for bonafide homoeopathic students
/ practitioners via transmission of clinic proceedings to classrooms with your prior consent.

Consent
I have read the above instructions and understand that my interview may be video recorded for the purpose
of study & teaching, I give consent for the same.

Signature

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This questionnaire has 7 parts:-
1. Description of your main complaint / complaints.

2. About your past illnesses, vaccination details and the developmental history. It also
includes
3. Details on medical history of family members. Please take time to answer this part,
preferably
4. Taking the help of your family members.

5. Personal history that covers all your allergies and addictions, likes, dislikes, etc.

6. Deals with the factors that affect your health. Please think carefully about each of the
factors
7. Mentioned and write what specific effects they have on you.

8. About your mental state and your emotional nature. Please write in this part about your
9. Situation in life and about all the things that are bothering you. Be totally frank and open.

10. How you were as a child.

11. Parts of the body affected.

Please get the following documents with this form

1. A reference note from your referring doctor.
2. All your recent & old medical reports(e.g. C.B.C., ESR, U.S.G, X-ray plates,
electrocardiograms, etc)
3. Any document/prescription connected related to past homoeopathic treatment.

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Details of present illness.

What are your complaints?

Since when are you having the complaints?

Location: Please give the exact location of sensation, pain or eruption. Also describe where
the pain or sensation spreads.

Sensation: Express the type of sensation or the pain that you get in your own
words. Express the sensation or pain as it feels to you.

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Origin of cause: Can you trace the origin of the present illness to any particular
circumstance, mental upset, illness, incident or accident? (E.g. shock, worry, errors
in diet, overexertion, overexposure to cold, heat, etc.)

What are the factors that influence your trouble? E.g. weather, food, pressure,
anxiety, etc. or any other (Please refer to part 4 on page 19 and 20 for a detailed list
of the factors).

Please mention how each factor affects you, whether it increases or decreases your
complaint, and also how much does it affect your complaint. E.g. headache worse
by even little exposure to sun, headache better by pressing the head.
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Sr. no. Where is the trouble? What exactly do you What are the factors Any complaint or
feel that make this symptom
Or have there? trouble better or associated
Worse? With this
complaint.

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 PREVIOUS DISEASES & DRUGS USED

Every disease, poisoning, drug or accident leaves its mark and remains as a weak
point in the system, much more than we imagine. Homoeopathic treatment takes into
account all these details of the past and thus removes all the weak points. Thus your body is
strengthened. That is why it is necessary for us to know about all the ailments you have
suffered from in the past and the treatments you have taken.
In the list below, circle around names of ALL major illnesses suffered so far and on the
next page give its relevant details.

Typhoid Measles Malaria Miscarriage.

Cholera German measles Jaundice Abortion

Food Poisoning Chicken-pox Any Liver Curetting

Worms Small-pox Spleen or Sickness during

Diarrhea Mumps Gall Bladder Pregnancy etc.

Dysentery Whooping cough Disease Prolapse of uterus

Malnutrition Any venereal Any heart trouble , Nephritis (Kidney or urine

trouble)

Rickets Disease like Blood pressure ,

Diabetes etc.

Rheumatism Syphilis Giddiness

Prostate trouble

Backache Gonorrhea etc.

Any operation such as Tonsils , Diphtheria, Septic Tonsils, Adenoids Recurrent infections – Any serious shock , grief ,
Abdomen , Appendix , Hernia , Sinusitis Bronchitis –Eosinophilia Cold 0-Fever-Chill. disappointments, fright ,
Piles, Uterus , Renal Stone , Pneumonia Asthma –Pleurisy—T.B. mental upset , depression or
Gall Stones, Phimosis , nervous break down
Hydrocele , Cataract etc. Mode
of anesthesia : general –local

Chronic Headaches, Any major accident or injury to body or head. Any occasion of Skin diseases like Pimples,
Numbness, Cramps, Fits, unconsciousness Boils, Carbuncles, Ringworms,
Convulsions Polio, Paralysis Fungus, Scabies, and Eczema.
etc. Meningitis –Any Lumbar
puncture done. Any major bleeding from any part of the body.
Ulcers on any part of the body.

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 DETAILS OF YOUR PAST ILLNESS
Diseases suffered Approximate Age Duration Whether you completely Medicines & treatment Any other particulars
from recovered taken

Any extra remarks of information:

Mention any drugs, tonics, stimulants etc. That has been used by you at any time in life.

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FAMILY INFORMATION

List of major Relationship Alive Age Diseases Cause of

diseases /dead death

Paternal Grand
Anemia
Father
Cancer
Paternal Grand Mother
Diabetes
Maternal Grand Father
Insanity
Maternal Grand Mother
Rheumatism
Father
T. B. /Pleurisy
Mother
Leprosy

Diseases Suffered

Paternal Uncles
Epilepsy/fits

Paternal Aunts
Bleeding tendency

Maternal Uncles
Urticaria

Maternal Aunts
Eczema

Cousin Brother &

Asthma
Sister on Father’s side

Paralysis
Cousin Brother &
Sister on Mother’s side
Hypertension

Heart trouble

Kidney disease

Liver disease etc.

Did any of your

relatives have trouble
similar to yours

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* How many brother –sister are you? (Including those who died, if any).
Provide information about them in the table below. Indicate your position by writing ‘SELF’.

SR.NO Brother /Sister Alive /Dead Age Diseases suffered

1.

2.

3.

4.

5.

6.

7.

8.

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 DEVELOPMENTAL HISTORY

*About your birth

Did your mother have any problem during pregnancy?
Did she take drugs during pregnancy? What were they?
Was there any difficulty about your birth? Give details.
*At what age did you start?

Teething Urine Control Bed wetting

etc.

Sitting

Standing Eating indigestible Like chalk,

lime, and earth. Slate-pen
Walking

Speaking Any other problem about Your

growth & development

Tick mark (X) if any animal bites such as:

Dog Rat Snake Scorpion

Mention if any other:

Did you take anti-rabies or anti –venom or any other treatment?
*Vaccination & Inoculations:
Indicate number of times you were vaccinated for the following:

Small pox Polio Cholera Measles

Triple B.C.G. Typhoid Tetanus

Was there any reaction or particular trouble after any of above vaccinations of inoculations?

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Give details:
(if married) How is the health of your husband /wife:
*Number of children living and dead. If dead, state causes:
Mention ages of children and their condition of health.

Child’s name Male/Female Age Diseases Suffered

Any abortions, miscarriages or still birth?

Your Habits How much

Smoking

Snuff

Chewing Tobacco

Alcohol

Tea

Sleeping Pills

Laxatives /Purgatives

Any other

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 PERSONAL HISTORY.

APPETITE AND THIRST

How is your appetite?

When are you hungry?
What happens if you have to remain hungry for long?
How fast do you eat?
How much thirst do you have?
Any particular times are you especially thirsty?
Do you feel any change in your taste and feeling in your mouth?

Please Put one plus mark (+) if you like/dislike the food or if the food disagrees. Put two
plus marks (++), if you strongly like/dislike the food or if the food strongly disagrees.
Please mention any other specific food items or drink that you really crave or like, at the
bottom.

Foods Like Dislike Disagrees Foods Like Dislike Disagrees

Bitter Eggs
Salty Spicy food
Sweet Meat
Sour Fish
Bread Cabbages
Butter Onions
Fats Warm
food/drink
Milk Cold
food/drink
Coffee Fruits
Mud/chalk Anything else

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STOOL
Do you have any problem regarding your stools?
When and how many times a day do you pass stools?
When is it urgent?
Do you have any problem about bowel movements?
Do you have to strain for stool? Even if soft?
Do you have belching or passing gas? Describe its character.
How do you feel after passing gas up or down?

URINATION & URINE

Any problem about urine?
Any strong smell? Like what?
Do you have any trouble before, during and after passing urine?
Any difficulty about the flow? Slow to start, interrupted, feeble dribbling etc.?
Any involuntary urination? When?

SWEAT/PERSPIRATION-FEVER-CHILL
How much do you sweat ?
Where and on what part do you sweat most?
Do you perspire on the palms or soles?
Is the sweat warm, cold, clammy, sticky, musty, greasy, stiffens the linen etc.?
What is the smell like? E.g. foul, pungent, sour, and urinous.
What color does it stain the clothing?
Is the stain easy to wash off or difficult?
Any symptoms after sweating?
When do you get fever or chill?
What brings it on?
Do you experience any sense of heat or cold?
Any part of your body at any particular time?

CHEST-HEART – COLD – COUGH

Do you catch cold often? If so, how?
Describe the symptoms, nature of discharge etc.
Is there any trouble with your CHEST or HEART?
Is there any trouble with your voice or speech?

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Is there any difficulty in breathing?
Do you have cough?
Is it more at any particular time?
Sleep
Describe your posture in sleep. (E.g. on back, abdomen, sides) Are you uncomfortable in any position?

How is your sleep pattern?

During sleep do you grind / snore / dribble saliva / sweat / keep mouth open / walk / talk / moan /
Weep / become restless / wake up with a jerk, etc.?

Describe anything unusual about your sleep.

How much do you cover / uncover any parts?

Sexual sphere
How do you feel after sexual intercourse?

Any particular feeling or symptoms that appear before, during or after sexual intercourse?

Any dislike or aversion for sexual intercourse?

How many times in a week do you have sexual intercourse?

Do you masturbate? What is the frequency? What is its effect?

Do you suffer from any sexual disturbance?

Any excessive indulgence in sex in past and present?

Any homosexual inclination?

Did you suffer from any sexually transmitted disease, like Syphilis, Gonorrhea, Herpes, H.I.V., etc.?

Any recurrent infections of the genital organs?

Which method do you use for family planning (contraception)?

For men

Is there any difficulty in erection?

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Do you suffer from weak erection, failing erection? Describe.

Is there any premature ejaculation?

Any complaints of nightfall or seminal emissions?

For women
Any dryness, itching, discomfort, bleeding, burning or pain in vagina before, during or after sexual
intercourse?

Any pain in abdomen after intercourse?

Menstrual history

At what age did your menses start?

How are the menses; regular or irregular?

Did you have any trouble?

How many days is your monthly cycle?

Menstrual flow

Duration (days):

Quantity of flow (e.g. profuse, scanty, moderate):

Color of flow:

Smell if any from the flow:

Staining, if any (Color of the stains):

Are the stains difficult to wash?

Do you have any complaints before, during or after menses? If so, describe.

If menopausal, mention the age of menopause. Any complaints around that time?

Did you experience any symptoms during menopausal period?

Is there any white discharge?

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If so, mention the nature, color, consistency and smell of discharge.

When and under what circumstances is it more or less?

Does the discharge have any relation to menses?

Any itching, burning, etc. due to discharge?

Do you pass gas from vagina?

Any trouble with breasts?

Obstetrics history

Pregnancy Details

Number of times you have conceived:

Number of times your pregnancy reached at or above 7 months:

Any history of abortion / miscarriage? If yes, at what month of pregnancy? Reason for the same.

Any complaints during pregnancy, e.g. nausea, vomiting, etc?

Were there liking / disliking for, any food / drink during any pregnancy?

What was your mental state during pregnancy?

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Any fetal abnormality detected during investigations?

Delivery

How many times have you delivered?

Were your deliveries full term / early / delayed?

Were they normal deliveries?

Were they Caesarian section / forceps / vacuum delivery? Reason?

Lactating history

Did you breast feed? If yes, for how long?

Any complaints during that period?

After how much time of your delivery did you get menses again?

FACTORS THAT AFFECT YOU

Below is a list of things that you are exposed to. Each of these factors may affect you
in a particular way. Please write in what way you are affected by each of the following. Do
you feel worse or better in any way from each of the factors? For instance take the factor
"sun". Suppose by going in the sun you get a headache, and then write "Headache”
opposite to "sun".
Take another example. If in hot weather you feel uneasy, and then write "Uneasy"
opposite to "Hot Weather” in the column.
In this way write the effect of each factor on you. Especially write the effect each
factor has on your main complaints. For instance if your main complaint is asthma and this
is worse when lying on the back then opposite to "lying on the back "write "asthma
becomes worse"

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 Sometimes one factor may make you feel worse in some respect, and better in some
other respect, For instance cold air may cause headache but headache but make you feel
better in general. If this is so, please mention this difference clearly.
This section is most important. Do not go through it hurriedly. Think carefully
about the effect of each factor before you write.

Effect Effect
Hot weather Walking
Cold weather Running
Rainy weather Climbing stairs
Cloudy weather Going downstairs
Change of season Riding in bus, car etc.
Thunder –storm Lying
Covering Lying on back
Warm bath Lying on left side
Sun Lying on right side
Cold bathing Lying on abdomen
Lying with head low Drinking
Sitting After sexual intercourse
Sitting erect Dust
Standing Smoke
Looking up Touch
Looking down Pressure
Looking from high places Massage
Looking at moving object Tight clothes
Noise Before sleep
Sudden noise During sleep
Music After sleep
Light After afternoon nap
Strong smells Loss of sleep
When constipated Before stools
Before urine During stools
During urine After stools
After urine Coughing
Before menses Sneezing
During menses Laughing

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After menses Talking
After Sweating Reading
When Fasting Writing
After eating Stooping
Before important engagement Passing gas
Before exams After hair cut
When angry Combing hair
When worried Brushing teeth
When sad Moonlight
After weeping Opening the mouth
Consolation /sympathy Smoking
In a crowd Hanging the limbs
In a closed room Hanging the arms
When thinking of illness Near sea
Full noon /new moon Shaving
Morning Stretching
Afternoon Swallowing
Evening Listening to others talk
Night Vomiting
Bathing Yawning
Draft air Moving the eyes
Biting or chewing Opening the eyes
Blowing nose Closing the eyes
When alone Getting feet wet
In company Over eating
Physical exertion Working in water
Belching Fanning

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 Circle types of dream that you have
Animal Robbers Travelling Houses Death, Whose?

Cats-dogs Thieves Riding Fruits Dead bodies

Horse Anxious Flying Trees Dead person

Wild animals Fearful Swimming Water Parts of Body

Snakes Ghosts drowning Snow Suicide

Being Hungry Fire Accidents Talking Business

Being Thirsty Lightning Falling Singing Money

Drinking Storm Shooting Dancing Day’s work

Eating Rain Wars Pleasant Forgotten work

Vomiting Romantic Pain Praying Failure /exams

Passing stool Sexual pleasure Illness Religious Unsuccessful efforts for

what

Urinating Rape Sickness Temple

Missing train

Blood – bleeding Nakedness Mutilations Church

Being unprepared

Excrements / soiling God

Grief Police Misfortunes If any other, specify

Weeping Imprisonment Insecurity In the space below:

Vexation Crime Danger

Quarrels Murder Being pursued

Jealousy Killing By whom?

Insults Poison -for what?

Of people Of events Physical Exertion

Children Remote Mental Exertion

Parties Recent Fatigue

Feasts Future Colored

Marriage Prophetic Multi-Colored

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 MIND
It is now universally acknowledged that your mind has tremendous influence on your
body. For giving proper treatment it is necessary for us to understand your emotional and
intellectual nature. We can thus treat you as a whole.

Are you anxious? About which matters?

Are you fearful of anything such as

Animal’s people being alone, darkness,

Death, diseases, robbers, sudden noises,

Thunder, of the future, of something

Unknown, high places, etc.?

Are you doubtful or suspicious? Of what?

What are you jealous about?

Of whom? From what symptoms do you suffer when jealous?

In which matters are you impatient?

Hurried?

How long do you remember hurts caused to you by others?

How much revengeful are you?

What are you proud of? Does your pride get easily hurt?

Depressed, Brooding, etc.?

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Do you ever become suicidal? When?

If so in what manner do you contemplate to end your life?

Even then, are you afraid of dying?

When are you cheerful?

Are you sexual-minded?

Any unwanted thoughts any time?

What are they?

Have you any imaginary sensations or fears?

Do you hear voices, or that you are called, or anything else in this line keeps on occurring in
your mind unduly?

How is your memory?

For what 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 and consolation?

Are you easily irritated?

What makes you angry?

What bodily symptoms do you develop?

When angry? E.g. trembling, sweating etc.

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Do you like company? Or like to remain alone?

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

What are the greatest grief’s that you have gone through in your life?

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

What activities you deeply like?

Are there any matters which you deeply dislike?

In your opinion, which aspects of your mind and moods are not agreeable to you?

Inspite of your awareness and maturity, are you unable to change these these aspects?

Give a clear cut picture of your situation in life and your relationship

With each of your family members, friends and associates in work.

How does the future look to you?

Are you worried or unhappy over any and personal, domestic, economical, social or any
other condition?

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If so describe in detail:

CHILDHOOD

Describe your nature as a child?

What were your fears as a child?

Any recurrent dreams in your childhood?

Any incident in your childhood that had a major effect on you?

Do you know of anything about your mother's history during pregnancy?

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 FOR CHILDREN or YOU AS A CHILD
(IN CASE OF ADULTS )
1) Please tick mark once (X) if the child or you as child had any of the following qualities:
Tick mark twice (XX) if they are more intense:

Tick Here Tick here

Obstinacy Unusual fears
Temper tantrums Shyness
Disobedience Unusual attachments (to whom)
Aggression Habits like :-
Hyperactivity Biting nails
Destructiveness Thumb –sucking
Courage Picking and playing with
Possessiveness (a) mother’s body parts
Competition-winning spirit (b)shawls , handkerchiefs
Sibling jealousy (c) anything else
Any special skills Religious
Unusual desires (for what ) Dullness of memory
Boasting Slowness (in what)
Stealing Laziness /Indolence
Telling lies Sensitive/Emotional

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 PARTS OF BODY AFFECTED

Any complaints about Vertigo: Do you have giddiness or vertigo?

Faintness: Do you ever feel faint? When?

Head: Do you get headaches?

Eyes & Vision: e.g. redness, burning, difficulty in reading, etc.

Ears & Sense of hearing: e.g. ear pain, difficult hearing, etc.

Nose & Sense of smell: e.g. bleeding from the nose, any problem with smell, etc.

Face & Facial expression: e.g. acne, pigmentation, moles, warts, etc.

Mouth: e.g. ulcers, bad smell from mouth, etc.

Teeth & Gums: E.g. carious teeth, stained teeth, bleeding or swollen gums, etc.

Tongue & Taste: E.g. sense of taste, any cracks, coating, etc.

Lips: E.g. cracked, peeling of skin, etc.

Throat (including tonsils): E.g. pain, difficulty in swallowing, trouble with voice or speech, etc.

Back & Limbs

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Do you have any trouble in back, limbs or joints? Describe in detail.

If there are pains, do they extend in any direction or shift?

What brings on the pains or makes them worse / better?

Is there any abnormality, swelling, numbness, paralysis, etc. in any part of the body?

Skin

Do you have complaints like itching, eruptions, ulcers, warts, corns, peeling, change in color, spots, etc.?

If yes, describe.

Nails: Is there any complaint or abnormality of the nails or the skin around?

Hair: Is there any complaint with the hair such as falling, graying, dandruff, dryness, oily, poor /

Excessive / unusual growth?

General

Do the wounds take a long time to heal?

Is there any tendency for formation of keloids or pus?

Do you have a tendency to bleed?

Is there any trembling? When?

Is there any sense of weakness? Where?

When is it more and what causes it?

Please draw / color something which comes to your mind spontaneously at this very moment.
Or something that you draw / doodle repetitively.

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