SCIENCE OF HOMEOPATHY

A Dialectical Homeopathy Website By Chandran Nambiar K C

CASE RECORDING FORM

COPY AND PASTE THIS FORM INTO A WORD DOCUMENT. FILL UP WITH ALL RELEVANT INFORMATION IN DETAIL< AND SEND AS EMAIL ATTACHMENT TO

similimum@gmail.com

 

CASE RECORDING FORM

 (Carefully answer the questions given below. Answers should be in all their details, and associated information. Do not ignore any of the subjective or objective symptoms)

 

Name: 

Address :

 

Phone :                                                           Email :

Occupation:

Age

Height:                                                Weight :

Male/ Female:

 

Married/unmarried/widow :
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1. What is your chief complaint (CC)?

 

 

 

2. When did this problem begin? What happened in your life around that time? What do u think cause it?

 

 

3. What aggravates the CC? (certain types of foods or weather,movement,light,noise,heat/cold,or anything else that you can think of )

 

 

4. At what time of the day or night is CC the worst ?specify an hour if you can

 

 

 

5. What symptoms can you identify the accompany the CC?

 

 

6. Which position do you dislike the most; sitting, standing, and lying?

 

7. Do you perspire a great deal? if so, when and where on the body >(feet,head,hair,armpits,etc)

 

 

8. What time of day tends to be a down time for u?

 

 

 

9. What do you worry about how do you deal with worries?

 

 

10. Do you tend to be neater and more fastidious than those around you, more casual?

 

11. Do you cry easily? in what situations

 

 

12. When you are upset, do you tend to tell a lot of people or keep it to yourself?

 

 

 

13. On what occasions do you feel despair?

 

 

14. In what circumstances do you feel jealous?

 

 

15. When and on what occasions do you feel frightened ?any fears ?(darkness. being alone,altitude,flying,elevators

 

 

16. What is the greatest grief’s that you have gone through your life? How did you react?

 

 

 

17. What are the greatest joys you have had in your life?

 

18. In what situations do you feel the blues, depressed, sad, and pessimistic?

 

 

 

 

19. What bothers you most in the other public ?how if at all, do u express

 

 

 

 

20. Do you have lack of self-confidence and poor sense of self worth?

 

 

21. Do you have any recurring dream? What is the dream?

 

 

 

22. What would you need to feel happy?

 

 

 

23. What do u do for work,(ideally, what would to you like to do )

 

 

 

24. If you had an expected week from work, and 1000 what would you do?

 

 

 

25. How do other people view you?

 

 

 

26. What would you like to change most about yourself?

 

 

27. How do you feel before, during and after meals? How do you feel if you go without a meal?

 

 

 

28. What would you most like to eat (if you did not have to consider calories, fat, anything you have read about the right way to eat)?

 

 

 

29. What foods do you dislike and refuse to eat?

 

 

30. How much do you drink in a day? Includes soda, juice, coffee, tea, milk, and alcoholic beverages as well as water .how much thirsty you feel?

 

 

 

31. What hours do you sleep? Do you tend to wake up at particular time? Why? What makes you restless or sleepy?

 

 

 

32. Do you do anything during sleep ?(speak,laugh,shrick,toss about, grind your teeth, snore)

 

 

33. How do you feel in the morning?

 

 

34. No. of pregnancies, no of children, no of miscarriages, no of abortions

 

 

 

35. At what age did your menses begin? If you have gone through menopause, at what age?

 

36. How frequently do they (or did they) come?

 

 

 

37. What about their duration, abundance, color, time of day when flow is greatest; any odor or clots?

 

 

38. How do you (did you) feel before, during and after menses?

 

 

39. What medications are you taking at present?

 

 

 

40. How frequently do you get colds and flu’s?

 

 

 

41. Have you had any childhood illness twice, or in a very severe form, or after puberty?

 

 

 

42. Have you had vaccinations since the standard childhood ones? Have you ever had an adverse or unusual reaction to vaccination?

 

 

 

43. Have you had any surgery? What and when?
 

 

 

44. Have you had at anytime (mention year); what therapy was given?
A) Warts: where? When? How treated?

b) Cysts: where? When? How treated?

 

 

c) Polyps: where? When? How treated?

 

 

d) Tumors: where? When? How treated?

 

 

 

45. Do you tend to have any discharges (nasal, vaginal, etc)? color, consistency:

 

 

 

46. Sensitivity:

a) Do you have been oversensitive to any substances like food, drugs etc.?

 

b) Do you need fewer anesthesias than others, or have a hard time coming out of it?

c) Do you tend to react to vitamins and herbs and/or need hypoallergenic vitamins?

 

d) Are you sensitive to paint fumes, exhaust, dry cleaning fluid, fragrances, etc.?


47. Family history: mention diseases, causes and ages of deaths of father,mother,sisters,brothers and grandparents on both sides

 

48. What else would you like to tell me about yourself or your conditions??

 

 

 

 

 

 

 

 

 

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