THE NATIONAL ACADEMY OF HOMOEOPATHY, INDIA

PATIENT DETAILS

Name of the Patient:
Sex:
Age:

Address:
Email Id:
Occupation:

Weight:
Height:
Date of First Visit:
PRESENT COMPLAINTS

Write down in details about the mode of onset of complaints :
(sudden or gradual, progressive or non progressive)
Duration:
Cause for the present complaints:
(example after an injury or mental shock, etc)
Any particular sensation you feel in the affected parts:
The factors that increase of decrease the complaints :
(example pain increased on walking or better by heat, etc.)

PHYSICAL GENERALATIES

Any season or time of the day or temperature that increases or decreases your complaints


a) THERMAL:Hot or Cold
b) WEATHER/ SEASON:
c) TIME:
d) SIDES of the body where the complaints are localized or have started: right or left:
APPETITE

A)Character:

B)Eating Habits:

C)Any specific desires or aversion to particular food or drinks or if you are disordered by a particular food item:
TASTE

Label
TONGUE

TONGUE

COATING

COLOR
THIRST
THIRST

QUANTITY

INTERVAL

DESIRES /AVERSION
URINE

Number of times
Quantity
Appearance
Color
Odour
Sediments
Constituents
STOOLS
Number of times
Evacuation
Stools
Consistency
Color
Odour
Associated with
PERSPIRATION

Perspiration
Character
Site
Color
Odour
SEXUAL

Orientation (and are you comfortable with it?)
Desire
Erection
Seminal Discharge
Coition
Masturbation
MENSES

At what age did you achieve Menarche or Menopause?
Cycle
Quantity & Duration
Character of Flow
Associated Symptoms
Pain (before, during or after menses)
Does the onset of menstruation aggravate or ameliorate any other complaint?
SLEEP

Character
During
Postures
Position
DREAMS

DREAMS
MENTAL GENERALITIES




A)How is your anger?
B)Are you hot or short- tempered?
C)Are you irritable or quarrelsome?
D)Do you express your anger freely or can’t express and brood about it for a long time?
E)Do you release your anger by shouting or throwing things or by violence, etc?
F)Do you vent out your anger on some-one else who is unrelated to the cause of anger? (Example family)?
(2)Are you very critical or censorious of other people’s work?
(3)Have you faced any form of indignation in the family or your work?
4)Does the feeling of Jealousy come to you very easily?
5)Are you Mischievous or Obstinate or upset by slightest contradiction?
6)Do people around you call you courageous or Egoist or Dictatorial, or complaining?
7)Are you basically a sad person? Do you have recurrent feelings of Dullness or being Morose? Are you affected by a grief?
8)Are you Serious by nature?
6)Do people around you call you courageous or Egoist or Dictatorial, or complaining?
9)Do you think you are a Hypochondriac meaning over-concerned about your health?
10)Do you have inferiority complex?
11)Are you a Happy go lucky type of person? Or are Haughty or Moody?
12)In a given situation can you cry or laugh easily?
13)Do you have a nervous or anxious temperament?
14)Do you anticipate things un-necessarily? Do you have any particular Fears
15)Do you yield to any and every one? Are you over-sympathetic or over-religious?
16)Are you an impatient or impulsive person?
17)Do you like to be industrious or are you lazy?
18)Do you think you are very restlessness?
19)Do you speak much?

1) A)How is your general perception or feeling about your surroundings, family friends or co-workers?
B) Is your understanding generally clear or are you generally confused?
C)Do you have imaginations?
D)Are you dull (Absentminded, Unobservant)?
E)Do you have hallucinations or illusions? Do you lack concentration?

2)A) How is your Memory
B) Do you make silly mistakes very often?
C)Have you lost your memory completely of a particular event or time frame of your life?

3)A) How is your Thinking
B) Is it your habit to makes many plans and lack the will to implement them?
C) Are you generally absorbed or buried in your own thoughts?
D) Do you keep on brooding?
E) Or dwell upon past occurrences?
F) Are your ideas fixed, changeable, or you have absolute lack of ideas?

a) Violent
b)Immoral
c) Emotional

d)Absurd
e)Indifferent

unusual desire for or aversion to Family
unusual desire for or aversion to Work
Unusual desire for or aversion to
LIFE HISTORY

Briefly describe all major incidents in your life and how it has shape you and affected you?
PHYSICIAN’S OBSERVATIONS

PHYSICIAN’S OBSERVATIONS
PERSONNAL HISTORY

PERSONNAL HISTORY
PAST HISTORY

PAST HISTORY
FAMILY HISTORY

FAMILY HISTORY
CLINICAL EXAMINATION

CLINICAL EXAMINATION (by your physician)
INVESTIGATION REPORTS

INVESTIGATION REPORTS