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Online Counsltancy

Our clinic provides online consultation using our web site. Your One-Stop solution for all health complaints that need Homeopathy! Speciality clinic is an online homeopathic consultation service that you can avail of, from the comfort of your home/office.

Personal Details

Your Name:   Occupation
Telephone No.   Marital Status
Zodiac Sign   Religion
Diet   Siblings
Blood Group   Address
Date of Birth  
Referred by  
Chief Complaints  

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
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      
(Walking-Talking-Teething-Growth Development Incontinence of Stool / Urine)

Appetite Cravings
Aversions Thirst
Stools Urine
Flatulence/Eructations Perspiration

Medical History

(Check all that apply)
Asthma Chronic Bronchitis
Allergy (sensitive) to any or various substances including food & pollens 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

Any Other Complaints Vertigo/Giddiness
Head Eyes & Vision
Ears & Hearing Face & Facial Expressions
Mouth <-> Taste <-> Tongue Throat
Teeth, Gums
[Caries, Bleeding Gums Dentition, Wisdom Teeth ]
Skin / Nails
Chest Stomach / Abdomen / Rectum

Menstrual History

Colour Duration
Lochia Quantity
Odour Leucorrhoea
Staining Flow
Mental State

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? 
Obstetrical History
(Pregnancy/Delivery / Abortion / Puerperium)
Menopausal Details
Breast Complaints


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?
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.


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


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Appointment Request

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Treatment Plan

Who is well but not fit completely

Online Consultancy

Consulting Homoeopath

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