DR.

Wellness ClinicSANKARAN’S CLINIC

of Jonathan Breslow LAc., CCH, RSHOMNA
Wellness Clinic of Jonathan Breslow LAc., CCH, RSHOMNA

CASE - RECORD
 PLEASE READ THIS FIRST BEFORE FILLING THIS FORM

You have come here to get well. We are here to select the possible medicine for you. In
order to do that, we depend on your co-operation. 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 make up.

This information enables us to select the remedy that removes your sickness. The medicine
also makes you well as a whole person.

  In   order   find   all   about   you,   we   shall   be   asking   you   many   questions.   Each   one   of   these  
questions  has  a  definite  meaning  and  significance  for  us.  There  is  not  a  single  question  that  
is useless. Even something that you may think 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 and frank and give us the fullest possible information on each point. Please
read  each  question  carefully,  think,  and  if  necessary,  consult  someone  close  to  you  and  then  
answer completely. Do not keep anything back. Remember, whatever you tell us will remain
absolutely  confidential.  

THIS QUESTIONNAIRE HAS 8 PARTS :

1. About your past illnesses. Please take time to answer this part with the help of your
family members before coming to us.

2. History of your present illness.

3. About all the parts of your body.

4. Deals with the factors that affect your health. Please think carefully about each of the
factors  mentioned  and  write  what  specific  effects  they  have  on  you.

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

6. About your sleep and dreams.

7. For children or how you were as a child.

8. In this part you are given instructions on how to report each of your complaints. Read
the  instructions  first.  Then  make  a  list  of  your  complaints  and  describe  each  of  them  
according to the instructions.
 1

CONFIDENTIAL

Date :

Name :
(Begin with Surname)

Address :

Telephone  :  Residence  :   Office   :

Mobile :
E-mail :

Age : Sex : Male / Female

D.O.B. :

Vegetarian / Non Veg. / Egg. Veg. Single/Married/Divorced/Widowed

Occupation (Nature of Work) : Education :

Referred to us by :
 PREVIOUS DISEASES & DRUG 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. Thus 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 illness so far suffered and on the next page give its relevant details.

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 Nephritis (Kidney or urine
2

Rickets disease like trouble, trouble) Diabetes etc.

Rheumatism Syphillis Blood pressure, Prostate trouble
Backache Gonorrhoea etc. Giddiness
Any operation such as Diptheria, Septic Tonsils, Adenoids Any serious shock, grief,
Tonsils, Abdomen, Appendix, Recurrent infections-Sinusitis disappointments, fright, mental
Hernia, Piles Uterus, Renal Bronchitis-Eosinophilia upset, depression or nervous
stones, Gall stones, Phimosis, Cold-Fever-Chill. Pneumonia break down.
Hydocele, Cataract etc. Mode Asthma-Pleurisy-T. B.
of anaesthesia : general-local
Chronic Headaches, Any major accident or Skin diseases like Pimples,
Numbness, injury to body or head. Boils, Carbuncles, Ringworms,
Cramps, Fits, Convulsions Any occasion of unconsciousness. Fungus, Scabies, Eczema.
Polio, Paralysis etc. Any major bleeding from any part of the body. Herpes, Urticaria, Allergy.
Meningitis - Ulcers on any part of the body.
Any Lumbar puncture done.
 Whether you
Approximate Medicines & treatment Any other
Diseases suffered from Duration completely
Age taken particulars
recovered
3

Any extra remarks or information

Mention any drugs, tonics, stimulants etc. that have been used by you at any time in life
 FAMILY INFORMATION

List of major diseases

Relationship Alive / Dead Age Diseases suffered Cause of death
Anaemia
Paternal Grand Father
Cancer
Paternal Grand Mother
Diabetes
Insanity Maternal Grand Father
Rheumatism
Maternal Grand Mother
T. B. / Pleurisy
Father
Leprosy
Epilepsy / Fits Mother
4

Bleeding tendency Diseases suffered

Urticaria
Paternal Uncle
Eczema
Asthma Paternal Aunts

Paralysis Maternal Uncle

Hypertension
Maternal Aunts
Heart trouble
Cousin Brother &
Kidney disease Sister on Father’s Side
Liver disease etc. Cousin Brother &
Sister on Mother’s Side
Did any of your relatives
have trouble similar to yours
 * How many brothers - sisters 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.

PERSONAL HISTORY
*About your birth :
5

Did your mother have any problem during pregnancy?

Did she take any drugs during pregnancy? What were they?
 Was  there  any  difficulty  about  your  birth?  Give  Details.
*At what age did you start.
Teething Urine control / bed-wetting etc.
Sitting Eating indigestibles like
chalk, lime, earth,
Standing slate-pencil etc.
Walking Any other problem about your
Speaking growth & development?

Tick mark ( ) if any animal bites such as:

Dog Rat Snake Scorpion
Mention if any order:
Did you take anti-rabies or anti-venom or any other treatment ?
* Vaccination & Inocculations :
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 vaccination or inocculations?
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 Disease Suffered
6

Any abortions, miscarriages or still births?

Your Habits How much?
Smoking
Snuff
Chewing tobacco
Alcohol
Tea
Sleeping Pills
Laxatives / Purgatives
Any other
 7

MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES : (AND DETAILED HISTORY

OF THE PRESENT ILLNESS, THE ONSET AND COURSE WITH DATES).

ORIGIN OF CAUSE : Can you trace the origin of the present illness to any particular
circumstance, accident, illness, incident or mental upset? (e.g. Shock, worry, errors in diet,
overexertion, overexposure to cold, heat etc.)?
 8

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 time are you specially thirsty ?

Do you feel any change in your taste and feeling in your mouth ?

Please put one tick ( ) if you Like/ Dislike the food or if the food disagrees. Put two marks
( ) , if you strongly Like / Dislike the food or if the food strongly disagrees.

Like Dislike Disagrees Like Dislike Disagrees

Bitter Eggs

Salt extra Spicy food

Sweet Meat

Sour Fish

Bread Cabbage

Butter Onions

Fats Warm food / drink

Milk Cold food / drink

Coffee Fruits

Mud / Chalk Anything else

 9

STOOL
Do you have any problem regarding your stools ?

When and how many times a day 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  difficulty  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, urinous.

 10

What colour does it stain the clothing ?

Is  the  stain  easy  to  wash  off  or  difficult  ?

Any symptoms after sweating ?

When do you get fever or chill ?

What brings it on ?

Do you experience any sense of heat or cold in

any part of your body at any particular time ?

Do you have burning or heat in your palms or soles ?

CHEST - HEAT - 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 ?

Is  there  any  difficulty  in  breathing  ?

Do you have cough ?

Is it more at any particular time ?

SEXUAL SPHERE ( GENERAL )

Any excessive indulgence in sex in past and present ?
Any effect on your health ?

How do you feel after sexual intercourse ?

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

Do you suffer from any sexual disturbance ?

Any habit like (masturbation etc.) in past

as well as present ? How often ?

Any homosexual inclination ?

 11

Did you suffer from any sexually transmitted disease ?

Syphilis ? Gonorrhoea ? Herpes ? HIV ?

Did you have increased desire or decreased desire for sex ?

What is the method you use for family planning (contraception) ?

FOR MEN
Any  difficulty  in  erection  ?

Wanted erection ? Unwanted erection ?

Weak erection ? Failing erection? Describe.

Any other trouble in sex ? Describe in details.

FOR WOMEN
Menses : How are the periods; regular or irregular ?

At what age did you start ?

Was there any trouble then ?

Mention interval between two periods.

Mention  number  of  days  of  flow.

Menstrual  flow:  Is  there  any  change  now  in  quantity,

colour, smell or consistency ?

Are  the  stains  difficult  to  wash  ?

Have  you  noticed  any  variation  in  quality

and  quantity  of  flow  during  menses  ?  How  and  when  ?

Do you suffer in any way before, during or

after menses ? If so, describe :

What symptoms did you suffer during menopause ?

Do you feel internal parts coming down ?

 12

Is there any white discharge ?

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

When and under what circumstances is it more or less.

Has the discharge any relation to menses ?

What is the effect of this discharge on your

general feeling? Or any of your symptoms ?

Any itching, excoriation etc. due to discharge ?

Do you pass any gas from vagina ?

Any trouble with breasts ?

ANY COMPLAINTS ABOUT :

VERTIGO - Do you have giddiness - vertigo ?

FAINTNESS : Do you ever feel faint ?

HEAD : Do you get headaches ?

EYES & VISION :

EARS & Sense of hearing :

NOSE & Sense of smell :

FACE & Facial expression :

MOUTH & Sense of taste :

About LIPS, MOUTH, TONGUE etc. :

TEETH, GUMS, e.g. carious teeth, bleeding gums.

swollen gums.

LIPS : Cracked, peeling of skin etc.

 13

THROAT ( including tonsils ) :

Any  difficulty  in  swallowing?

Do you have any trouble in your BACK, LIMBS

OR JOINTS? Describe in detail :

If you have pains, do they shift ?

In what direction do they extend ?

Is there any abnormality, swelling, numbness,

paralysis etc. in any part of the body ?

Is there any complaint of SKIN : such as

itching, eruptions ulcers, warts, corns,
peeling etc.? ( Describe its nature )

Any change in colour of the skin or

spots of any part of the body ?
Is there any complaint or abnormality of
the NAILS or skins around ?

Is there any complaint with the HAIR such

as falling, graying, dandruff, dryness, oily , poor
excessive or unusual growth ?

Do wounds heal slowly ?

Form keloid? Do wounds tend to form pus ?
Have you a tendency to bleed ?

Are your troubles one sided? which one ?

Or more on one side ?
Do they proceed from one to the other side ?
Or do they alternate or shift ?

Is there any trembling ? When ?

Is there any senses of weakness ? Where ?

When is it more or less ?
Is it in any particular part of the body ?
 14

FACTORS THAT AFFECT YOU

Below are the 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. In what way do they affect you.

For instance take the factor “sun”. Suppose by going in the sun you get a headache then
write “Headache” opposite to “Sun”.

Take another example If in hot weather you feel uneasy, 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”.

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 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

Riding in bus, car
Change of season
etc.
Thunder - storm Lying

Covering Lying on back

Warm bath Lying on left side

Sun Lying on right side

Cold bathing Lying on abdomen

 15

Effect Effect

Lying with head low Drinking

Sitting After sexual intercourse

Sitting erect Dust

Standing Smoke

Looking up Touch

Looking down Pressure

Looking from high

Massage
places

Looking from
Tight Clothes
moving object

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

After Menses Talking

After Sweating Reading

When Fasting Writing

After eating Stooping

 16

Effect Effect
Before important
Passing gas
engagement
Before exams After hair cut

When angry Combing hair

When worried Brushing teeth

When sad Moonlight

After Weeping Opening the mouth

Consolation /
Smoking
Sympathy
In a crowd Hanging the limbs

In a closed room Raising the arms

When thinking of
Near Sea
illness
Full Moon / New
Shaving
Moon
Morning Stretching

Afternoon Swallowing
Listening to others
Evening
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
 17

MIND

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

  In  order  to  understand  you  we  will  be  asking  certain  questions.  Answer  them  freely,  carefully  
and completely. This information will help us much in giving you the correct remedy. Also such
a remedy will help improve your mental make up.

Answer freely. Answer frankly. Answer completely.

Are you anxious ? About which matters ?

Are you fearful of anything such as

animals, people, being alone, darkness,
death, disease, 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 jealousy ?

In which matter 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 ?
 18

Depress, Brooding, etc. ?

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 ?
 19

What bodily symptoms do you develop

when angry ? e.g. trembling, sweating etc.

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 griefs 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 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 ?

When you are free, what thoughts come to your mind ?

 20

Are you worried or unhappy over

any personal, domestic, economical,
social or any other condition ?
If so describe in detail :

If asked for 3 desires or wishes in life, what will you ask for ?

SLEEP
Describe your posture in sleep,
on the back, side, abdomen etc.

Are you able to sleep in any position ?

In which position you can’t sleep ?

During sleep do you :

Snore? Grind teeth ?
Dribble saliva? Sweat ?
Keep eyes or mouth open ?
Walk ? Talk ? Moan ? Weep ?
Become restless ? Wake up with a jerk ?

Describe if anything else is unusual

about your sleep : ( Sleepy,
Sleeplessness, etc. if so when )

How much do you cover ?

Do you have to uncover any parts ?
 21

Circle types of dream that you have

Animals Robbers Travelling Houses Death, Whose?

Cats - Dogs Thieves Riding Fruits Dead bodies

Horse Anxious Flying Trees Dead persons

Wild animals Fearful Swimming Water Part 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 Unsuccesful efforts ?

For what ?
Urinating Rape Sickness Temple
Missing Train
Blood-bleeding Nakedness Mutilations Church
Being unprepared
Excrements / God
soiling

Grief Police Misfortunes If any other, specify

in the space below:
Weeping Imprisonment Insecurity

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 Recents Fatigue

Feasts Future Coloured

Marriage Prophetic Multi-Coloured

 22

Please draw something that comes to your mind at present or your favourite drawing:
 23

FOR CHILDREN
OR
YOU AS A CHILD (IN CASE OF ADULT)

1) Please tick mark once ( ) if the child or you as child had any of the following
qualities  :  Tick  mark  twice  ( ) 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, handkerchieves

Slibling 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

2) Please write in detail, if the mother suffered from any physical or emotional stress
during pregnancy. Also describe the dreams the mother got during pregnancy.

3) Please describe any other aspects you feel are striking about the child.

4) Describe one incident from the child’s life when he/she very upset.
 24

HOW TO DESCRIBE YOUR COMPLAINTS

In homoeopathy, prescription is based on precise details of various symptoms from which

you suffer. To tell or write to a homoeopathic physician “I have a headache”, “an eruption”, or
“cough”, would not be enough. If you inform him “I have headache with sharp shooting pains
in the left side of the head and temple, these pains always come on when the slightest cold air
strikes the head, the pains are much less when lying down and covering up the head warmly
and much worse when rising up, walking about or when the head becomes cool”, then only
you   have   given   all   the   information   required   for   making   a   good   homoeopathic   prescription.  
The success of the prescription depends, largely, on how detailed is your description of the
symptoms.

We  require  the  following  details  about  your  symptoms.

LOCATION : Please give the exact location of sensation, pain or eruption. Also describe
where  the  pain  or  sensation  spreads.  Please  use  the  figure  on  page  24  to  indicate  location.

SENSATION : Express the type of sensation or the pain that you get in your own words
however simple or funny it may seem. You may have a sensation that a mouse is crawling
or the heart was grasped by an iron hand or you may have a pain which is cutting, burning
jerking, pressing. Express the sensation or pain as it feels to you.

WHAT  MAKES  YOU  WORSE  OR  BETTER  :  Many  factors  are  likely  to  influence  your  trouble.  
Some factors may cause the trouble to increase and some factors may relieve the trouble. A
detailed list of the factors is given on pages 14 to 16. Please refer to them when describing
each of your troubles and indicate which factors make the complaint better or worse.

DISCHARGES   :   You   may   have   a   discharge   from   ulcers,   fistula,   eruptions   the   skin,   lungs,  
eyes, nose, ears, mouth, private parts, etc. Please describe your discharge under the following
aspects.

  *   The  quantity  and  the  time  or  condition  under

    which  the  quantity  varies  i.e.  when  is  it  better  
or worse, increases or decreases ?

* The consistency; Is it thin or thick, stringy, or

clotted ?

* Is it like jelly, white of an egg, like water, sticky,

forming a scab etc. ?

* The odour, what does it remind you of ?

* Does it make the parts sore, and in what way ?

 25

Please  mark  in  the  below  figure,  the  locations  

of your trouble and write the exact sensation or Throbbing
type of pain you experience at those spots. For pain
example if you have throbbing pain on the right
side of you head please mark as shown

RIGHT FRONT LEFT BACK

FACE FACE
 26

IN THE FOLLOWING PAGES PLEASE DESCRIBE EACH OF YOUR COMPLAINTS IN

DETAIL IN THE MANNER DESCRIBED ON PAGE 24
COMPLAINT WHERE IS THE WHAT EXACTLY DO YOU FEEL WHAT ARE THE FACTORS THAT
NO. TROUBLE OR HAVE THERE MAKE THIS TROUBLE BETTER
OR WORSE
 28

Questionaire compiled by Dr. Rajan Sankaran. Copies can be had from Dr. Sankaran’s Clinic,
G 3, Beach Haven 1, Juhu Tara Road, Mumbai 400 049. Tel. 2610 3466 / 67.
This case record form is not copyright.
PRINTED BY : Thomson Press (India) Limited, Plot No. 5/5A, TTC Ind. Area, Thane Belapur
Road, Airoli, Navi Mumbai - 400 708.