Questionnaire for Patients

Homoeopathic Treatment Information Required

Let us try to understand what it involves, what you are expected to do and what it offers you.

It involves administering very minute doses of medicine for palliation or cure of you ailments. Look at following diagram.

Homoeopathic Medicine à Patient à Palliation / Cure

Our body can be conceived as comprising various subsystems like gastric system processing food, respiratory system providing oxygen etc. All these subsystems function in harmonious way under the dictate of nervous system which is also responsible for thinking and mental operations. Disturbances in this harmonious functioning, if out of range, produce disease. What homoeopathic medicines probably do is to assist the normalization of the function.

A close look at these operations will convince anyone the magnitude and intricacies of it. No wonder, each one of us differ in minute details in health as well as disease.

Therefore information we need from you is exhaustive. Please read the following and answer it carefully.

Name, Age, Sex, Address, Religion

Education, Occupation (Details of the work)

Marital status, present members of the family, their ages and occupation.

Write down your main complaint giving the following details about it.

Location: Area of the body where you feel it. How long you are suffering form it, how often you have it.

For Example:	i.	Pain in Right Upper abdomen going down up to thigh – 2yrs on and off.
	ii.	Fever – feeling of heat all over – every day

Sensation: It may be pain, giddiness, palpitation etc. Try to be accurate as for as possible.

For Example:	i.	Burning, sticking pain.
	ii.	Giddiness as if falling forward.

Modalities: Our body interact all the time with external and internal environment. This will affect you complaints.

For Example:

Your trouble may increase or decrease in specific season, pressure and heat may relive your pain and so on.

It will be more informative if you put through marking the extent to which a particular factor affects it.

For Example:

Pressure will relieve very slightly, better pressure. Or it may relieve marked by better by pressure.

For convenience a list of some of the factors is given below to think over.

i.		Cause: Circumstances which in your opinion have led to your ailments.

ii.		Time: Specific hours, day, night, periodicity, seasons, moon phases.

iii.		Temperature and weather: wet, dry, cold, hot, foggy etc. change of weather storm.
		- Bath: Hot, cold lukewarm
		- Sun, warm room, heat, wind, fan A/c

iv.		Rest, motion, position – Slow, rapid, ascending, descending, lying, turning in bed, walking, standing, sitting etc

v.		External Stimuli – Touch, pressure, hard pressure, light, noise, music etc.

vi.		The effects of physiological processes – eating, drinking, swallowing, defecating, menses, urination, perspiration etc.

Concomitant: It may be that along with your complaints at the same time you experience something else at other location. For ex. headache with pain in extremities etc.

Write down such complaints which occur at the same time.

We advise you to write down the above mentioned information in following format.

Location	Sensation	Modalities	Concomitants
Head	Throbbing	Better by pressure	With vomiting

Besides main complaints whatever other troubles you experience, write down in the same manner.

Mention illnesses you have suffered in the past, giving details as far as possible.

Write down the major illnesses of your parents, Brothers, sisters.

Self description

Weight, Height, Skin – Color, any peculiarity like rough, cracks, smooth etc. Hair, nails.

Digestion – appetite, craving and aversion for particular type of food, tendency to constipation, diarrhea, acidity, flatulence

Elimination – Stool, urine, perspiration, other discharges like sputum, nasal discharge etc.
Their color odor Consistency, other peculiarity like acrid, burning etc.

Menstrual cycle, pregnancy, labor, details.

Sexual function.

Sleep, dreams.

Mind: It is difficult to describe. Write down about your feelings from childhood till date describing the circumstances under which they arose. Try to describe the people in your family at work or in social context about whom you feel too much- may be love, hatred fear etc. Are you happy with your career? Your progress? Your life in general? If not, what are the deficiencies?

Send us the reports of your laboratory, radiological or other investigations if any.

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