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Personal Details

Marital Status
  • Marital Status
  • Single
  • Partnered
  • Married
  • Separated
  • Divorced
  • Widowed
Sex
  • Sex
  • Male
  • Female
Blood Group
  • Blood Group
  • O‌ Positive
  • O‌ Negative
  • A‌ Positive
  • A‌ Negative
  • B‌ Positive
  • B‌ Negative
  • AB‌ Positive
  • AB‌ Negative
  • Not‌·Known

Personal History

Childhood Illness: (Check all that apply)
Measles
Mumps
Chicken Pox
Rheumatic Fever
Rubella
Immunizations: (Check all that apply)
Tetanus
Hepatitis
BCG
Chicken Pox
MMR
Poilio
Have You Ever Had Following: (Check all that apply)
Arthritis
Diabetes
Hepatitis/jaundice
Venereal Disease
Dizziness
Epilepsy
Herpes
Sore throat Frequent
High Blood Pressure
Eczema
Cancer
Depression
Milestones
(Walking-Talking-Teething-Growth Development Incontinence of Stool / Urine)

Medical History

(Check all that apply)
Asthma
Chronic Bronchitis
Allergy (sensitive) to any particular factors like Food: Veg/nonveg, Inhalant means any particular smell like dust,Fumes, flowers,Agarbati, Smoking, Strong odour, Contact Allergens like clothes, ornaments,metals, Skin fungi, Allopathic Drugs.
Tuberculosis (TB)
Sinusitis
Warts
Glandular swellings (thyroid / tubercular / testicles)
Migraine/Headaches
Alcohol or any other addiction
Back or Neck Pain, Stiffness, Soreness

Family History

(Check all that apply)
Blood Disease/Clots
Father
Mother
Sibling
Grand Parents
Cancer
Father
Mother
Sibling
Grand Parents
Diabetes
Father
Mother
Sibling
Grand Parents
Epilepsy
Father
Mother
Sibling
Grand Parents
Heart Disease
Father
Mother
Sibling
Grand Parents
High Blood Pressure
Father
Mother
Sibling
Grand Parents
High Cholesterol
Father
Mother
Sibling
Grand Parents
Triglycerids
Father
Mother
Sibling
Grand Parents
Mental Illness
Father
Mother
Sibling
Grand Parents
Stroke
Father
Mother
Sibling
Grand Parents
Thyroid Disease
Father
Mother
Sibling
Grand Parents
Tuberculosis
Father
Mother
Sibling
Grand Parents

Any Other Complaints

Menstrual History

Complaints
Mental State
Cycle

Mental Symptoms

(Check all that apply)
Suspicious
Irritable
Feel Stressed/Tired
Laughing during talking
More worried about others
Talkative
Quiet
Wanted to do things in hurry?
Do you suffering from any anticipatory feelings? (Specify)
How would you describe yourself & your character?
Type of Dreams (specify)
Sleep (specify e.g. Troubled/Sound etc.)
motions (specify)
Sad Events (if any)
Mental State

Skin Problems (Present / Past) (Specify)

Obstetric History

No of Pregnancies?
No of Miscarriages?
No of Abortions?
(Pregnancy/Delivery / Abortion / Puerperium)
Menopausal Details
Breast Complaints

Sleep

Describe about your sleep ?
How's your sleep [Good / Bad / Okay] ?
Do you get sound sleep ?
Do you startle during your sleep ?
How do you feel on waking from sleep ?
How's your need of sleep [Great / Little / NO] ?
In Particular situation you get asleep ?
Do you snore during sleep?
During sleep do you have any habit of talking, walking, screaming, moaning, crying or keeping mouth or eyes open?
Describe your position / Posture during sleep?
Do you dream in your sleep?
is your sleep affected before / during menses?
How much do you cover during sleep?

Present Treatment

State present treatment with detailed information regarding medicines and its dose plus any herbal or vitamin supplements that you might be taking.

Diagnosis

Provide details of Diagnosis (if any). Write the Conclusion of the Clinical Reports (if any).
Ask an Expert

Get answers to your queries

Appointment Request

Book an appointment with us

Treatment Plan

Who is well but not fit completely

Online Consultancy

Consulting Homoeopath