HOMOEOPATHIC CASE TAKING FORMAT
RECORD-KEEPING
It is important that you must read this before giving record:
I try my level best to cure you with proper care. As it is just to inform you that in Homoeopathy it is
necessary to select a best remedy for you, I need your full co-operation and support. As in
Homoeopathy remedy selection depends upon the “Totality of Symptoms” so I will ask many questions
to you during this time period and you have to answer me for best prescription. Because Homoeopathic
system of medication depends upon “Individualization” so I will consider even a very minute and even
common symptom, might be I will help me out to select the best one. And all this include your
“Reactions to environment, Family history, personal history, past history” and relevant to above
mentioned data etc. so it is important that you should understand each thing that belongs to you as an
individual.
So, this information and your co-operation will enable me to select your best possible single remedy.
Regarding this one thing is most important that you should frank with me, and freely answer my
questions, and don’t think that this is useless question or this is not relevant to you, because might be
this one minute thing leads towards best prescription. And read everything in this Performa and try
your level best to answer of every question or even you can consult this with your any closed one to
complete this.
At the most important thing that keep it in you mind that whatever you are telling me or writing in this
Performa will be remain confidential.
PARTS OF QUESTIONNAIRE:
This questionnaire consists following parts:
1. History regarding your chief complaints.
2. History regarding your present illness
3. History and questions regarding you past history and family history.
4. Environmental factors relevant to your illness, so please think about each question carefully and
then answer.
5. Mental illness, this is very important portion regarding your history, so think carefully and answer
because sometimes in homoeopathy remedy selection depends upon “Psychology”
6. Dreams
7. Sleep
8. Especially for children or you are as a child
9. This portion is very important because in this portion you are given the instructions on how to
report each of your complaint, so 1st only read the given instructions and then make a list of your
complaints and then describe the each complaint according to the instructions.
CONFIDENTIAL
Name:
Age:
Sex:
Address:
Telephone: Work Place Contact#:
Religion:
Occupation (Type of work):
Education:
Vegetarian/ Non-vegetarian/Egg. Vegetarian single:
Divorced/Widow:
LMD:
EDD:
Date:
CHIEF COMPLAINTS:
PAST/PREVIOUS HISTORY:
In this history it is important to note that have you any disease in your past. Because, sometimes
current problem relates with previous one. No doubt it is a fact that any disease, Poisoning, Drug, or
any accident leaves it mark and remains in your system as a weak point, and that can be mush more
than our imaginations. In homoeopathic treatment it is necessary to know about all the previous
ailments to give strength your body. So, it is important that you tell us about your previous ailments
that you have suffered from in the past and the other treatments that you have taken.
Below a list is given just encircle that one disease/illness so far suffered and then move on next page to
give its relevant details
D.N D.N D.N D.N
Typhoid Measles Malaria Miscarriage
Cholera German measles Jaundice Abortion
Food Poisoning Chicken-pox Any Liver Currettings
Worms Small-pox Spleen or Sickness during
Diarrhoea Mumps Gall Bladder Pregnancy etc.
Dysentery Whooping cough Disease Prolapse of uterus
Malnutrition Any venereal Any heart trouble , Nephritis (Kidney or urine
Rickets Disease like Blood pressure , trouble)
Rheumatism Syphilis Giddiness Diabetes etc.
Backache Gonorrhoea etc. Prostate trouble
Any operation Diphtheria, Septic Tonsils , Adenoids Any serious shock , grief ,
such as Tonsils , Recurrent infections – Sinusitis Bronchitis – disappointments, fright ,
Abdomen , Eosinophilia Cold 0-Fever-Chill . Pneumonia mental upset , depression or
Appendix , Asthma –Pleurisy—T.B. nervous break down
Hernia , Piles,
Uterus , Renal
Stone , Gall
Stones, Phimosis
, Hydrocele ,
Cataract etc.
Mode of
anaesthesia :
general –local
Chronic Any major accident or injury to body or Skin diseases like Pimples ,
Headaches, head. Any occasion of unconsciousness Boils, Carbuncles, Ringworms,
Numbness , Any major bleeding from any part of the Fungus, Scabies , Eczema.
Cramps, Fits , body. Ulcers on any part of the
Convulsions body.
Polio, Paralysis
etc. Meningitis –
Any Lumbar
puncture done.
Regarding your past:
Cause of Duration Approximate age Any otherWhether youAny other
Disease/Disease medication andcompletely particulars
Suffered From treatment yourecovered?
are taking/ have
taken
Any other information you want to share regarding this:
Write the name of any Narcotic, Drug, Medicine etc. that ever you used in your life time:
FAMILY HISTORY:
Encircle the Disease you have from your any relation/Family member, also encircle that relation:
S.N List of Major Family Relationships Age Alive/Dead Cause Disease
Diseases of Relation
death
1. Anaemia Paternal Grand
Father/Mother/Maternal Grand
Father/Mother/Uncle/Aunt/cousin
Brother/Cousin Sister/Cousin’s
Brother or Sister from Mother’s
side/ Cousin’s Brother or Sister
from Father’s side
2. Cancer Paternal Grand
Father/Mother/Maternal Grand
Father/Mother Uncle/Aunt/cousin
Brother/Cousin Sister/Cousin’s
Brother or Sister from Mother’s
side/ Cousin’s Brother or Sister
from Father’s side
3. Diabetes Paternal Grand
Father/Mother/Maternal Grand
Father/Mother Uncle/Aunt/cousin
Brother/Cousin Sister/Cousin’s
Brother or Sister from Mother’s
side/ Cousin’s Brother or Sister
from Father’s side
4. Insanity Paternal Grand
Father/Mother/Maternal Grand
Father/Mother Uncle/Aunt/cousin
Brother/Cousin Sister/Cousin’s
Brother or Sister from Mother’s
side/ Cousin’s Brother or Sister
from Father’s side
5. Rheumatism Paternal Grand
Father/Mother/Maternal Grand
Father/Mother Uncle/Aunt/cousin
Brother/Cousin Sister/Cousin’s
Brother or Sister from Mother’s
side/ Cousin’s Brother or Sister
from Father’s side
6. T .B. /Pleurisy Father / Mother
7. Leprosy Paternal Grand
Father/Mother/Maternal Grand
Father/Mother Uncle/Aunt/cousin
Brother/Cousin Sister/Cousin’s
Brother or Sister from Mother’s
side/ Cousin’s Brother or Sister
from Father’s side
8. Epilepsy/Fits Father / Mother
Diseases From
1. Bleeding Uncle/Aunt/cousin Brother/Cousin
Tendency Sister/Cousin’s Brother or Sister
from Mother’s side/ Cousin’s
Brother or Sister from Father’s side
2. Urticaria Uncle/Aunt/cousin Brother/Cousin
Sister/Cousin’s Brother or Sister
from Mother’s side/ Cousin’s
Brother or Sister from Father’s side
3. Eczema Uncle/Aunt/cousin Brother/Cousin
Sister/Cousin’s Brother or Sister
from Mother’s side/ Cousin’s
Brother or Sister from Father’s side
4. Asthma Uncle/Aunt/cousin Brother/Cousin
Sister/Cousin’s Brother or Sister
from Mother’s side/ Cousin’s
Brother or Sister from Father’s side
5. Paralysis Uncle/Aunt/cousin Brother/Cousin
Sister/Cousin’s Brother or Sister
from Mother’s side/ Cousin’s
Brother or Sister from Father’s side
6. Hypertension Uncle/Aunt/cousin Brother/Cousin
Sister/Cousin’s Brother or Sister
from Mother’s side/ Cousin’s
Brother or Sister from Father’s side
7. Heart Troubles Uncle/Aunt/cousin Brother/Cousin
Sister/Cousin’s Brother or Sister
from Mother’s side/ Cousin’s
Brother or Sister from Father’s side
8. Kidney Uncle/Aunt/cousin Brother/Cousin
Diseases Sister/Cousin’s Brother or Sister
from Mother’s side/ Cousin’s
Brother or Sister from Father’s side
9. Liver Diseases Uncle/Aunt/cousin Brother/Cousin
etc. Sister/Cousin’s Brother or Sister
from Mother’s side/ Cousin’s
Brother or Sister from Father’s side
10.
11.
12.
If have any confusion regarding above details can ask and if you wants to add more can
write below:
How many siblings you have (Brothers & Sisters, including those who died, if any)?
Provide the information regarding above mentioned Question in the table below:
S.N Name of Brother/Sister Age Alive/Dead Disease if have any
1.
2.
3.
4.
5.
6.
7.
8.
9.
If you want to add more information regarding this you can write below:
PERSONAL HISTORY:
This history includes you personal from your childhood to till, or if child then take the history from close
relation like Mother/Father:
1. About you birth
2. Did your Mother take any drug during pregnancy?
3. Did your Mother have any disease/problem during Pregnancy?
4. Was there any problem during your birth give details if have?
5. At what age you start followings:
S.N Stage Age Yes No
1. Sitting
2. Teething
3. Standing
4. Walking
5. speaking
6. Habit of eating Indigestibles like
Lime, Chalk, Soil, Slate, Pen etc
7. Urine Control/Bed Wetting
8. Any other problem regarding your
Growth & Development
Encircle “Y” if there is any animal bite and if no then Encircle “N” :
S.N Name Y N
1. Dog Y N
2. Cat Y N
3. Snake Y N
4. Scorpion Y N
5. Rate Y N
If any other then mention below:
Did you ever take any anti-rabies or anti-venom or any other treatment like this:
History of Vaccination or any Inoculation if you have taken:
Indicate the number of times was Vaccinated for the followings:
S.N Name of Disease Number of times you vaccinated
1. Cholera
2. Small Pox
3. Polio
4. Measles
5. B.C.G
6. Typhoid
7. Tetnus
8. B.C.G + Typhoid + Tetnus Triple
Mention if you have any trouble or reaction from above mentioned
Vaccinations/Inoculations:
If you are “MARRIED” then give details about the health of your Husband/Wife:
Information about your children how many you have? Number of dead children if any, with
proper causes, inform about following details:
S.N Child’s Name Male/Female Age Alive / Dead Disease if any
1.
2.
3.
4.
5.
6.
Any other condition like:
· Abortion
· Miscarriages
· Still birth
Data of Personal habits:
S.N Personal Habits How much
1. Smoking
2. Snuffing
3. Alcohol
4. Chewing Tobacco
5. Sleeping Pills
6. Alcohol
7. Tea
8. Laxatives/Purgatives
9. Any Other
If you have any other information regarding above mentioned table write below:
MAIN COMPLAINTS WITH THEIR DETAIL HISTORY AND ASSOCIATION WITH THE RECENT
TROUBLES ALONG WITH OTHERS LIKE:
v Onset
v Course with detail
ORIGIN AND CAUSE:
Try to trace out your actual cause and origin of your Illness like:
· Any mental disturbance like Shock, Worry, Depression etc:
· Errors in Diet and Regimen:
· Over exertion:
· Exposure to Cold/Heat
THIRST AND APPITITE:
Give your answer correctly:
1. How is your appetite?
2. When are you hungry?
3. What happens if you have to remain hungry for long?
4. How fast do you eat?
5. How much thirst do you have?
6. Any particular times are you especially thirsty?
7. Do you feel any change in your taste and feeling in your mouth?
LIKES AND DISLIKES:
It is very much important that you must fill up the table given below carefully as most of the times
remedy selection depends upon your likings and disliking.
Please write “Y” if you like/Dislike something and write 2 times “YY” if you strongly like or dislike
something in the table is given below:
S.N Like Dislike Disagrees S.N Like Dislike Disagrees
1. Bitter 11. Eggs
2. Salt extra 12. Spicy food
3. Sweet 13. Meat
4. Sour 14. Fish
5. Bread 15. Cabbages
6. Butter 16. Onions
7. Fats 17. Warm
food/drink
8. Milk 18. Cold
food/drink
9. Coffee 19. Fruits
10. Mud/chalk 20. Anything
else
If you want to put any other information regarding above mentioned table please write below:
STOOL:
1. Do you have any problem regarding your stool?
2. When and how many times a day you pass stool?
3. When you feel urgency?
4. Do you have any problem about bowel movements?
5. Do you have to strain for stool? Even if soft?
6. Do you have belching or passing gas? Describe its character along with Aggravations and
Ameliorations
7. How do you feel after passing gas up or down?
8. Do you feel better/be upset before/during/after passing stool?
If you have any other information regarding your stool complaints then you can write below with detail:
URINE:
1. Any problem about the urine?
2. Any strong smell/odor? Like what?
3. Do you have any trouble before, during and after passing urine?
4. Any difficulty about the flow? Slow to start, interrupted, feeble dribbling etc.?
5. Any involuntary urination? When?
6. What is the colour of Urine write it correctly?
7. Do you feel Burning before/during/after urination?
8. Do you feel that you want to pass urine but unable to urinate?
9. Do you feel any sedimentation in urine after passing?
If you have any other information/complaint regarding urination you can write below with proper detail:
Patient’s signature:
Submission Date:
Follow up Date:
Prescription:
Rx:
