CASE TAKING FORMAT FOR ADULTS & CHILDREN
CASE - RECORD
PLEASE READ THIS FIRST BEFORE FILLING THIS FORM
You have get well. We are here to select the best possible medicine for you .In order to do that, we depend on your co-operation. HOMOEOPATHIC MEDICINE IS MAINLY SELECTED ON THE SYMPTOMS YOU GIVE US. If we are to make a successful prescription, we must know all the details of your sickness. We must also understand all the features that belong to you as an individual. This includes your reactions to various factors, your past and family history and your mental make up.
This information enables us to selection the remedy that removes your sickness. The medicine also makes you well as a whole person.
In order to find out all about you, we shall be asking you many questions. Each one of these questions has a definite meaning and significance for us. There is not a single questions that is useless. Even something that your may think is not connected with your trouble, may be the most important factor in deciding the correct homoeopathic medicine. That is why you must be free and frank and give us the fullest possible information on each point. Please read each question carefully, think and if necessary, consult someone close to you and then answer completely. Do not keep anything back. Remember, whatever you tell us will remain absolutely confidential.
THIS QUESTIONNAIRE FORM HAS 8 PARTS :
1. About your past illnesses and family illnesses. Please take time to answer this part with the help of your family members before coming to us.
2. History of your present illness.
3. About all the parts of your body.
4. Deals with the factors that affect your health.. Please think carefully about each of the factors mentioned and write what specific effects they have on you.
5. About your mental state and your emotional nature . Please write in this part about your situation in life and about all the things that are bothering you. Be totally frank and open.
6. About your sleep and dreams .
7. For children or you as a child .
8. In this part you are given instructions on how to report each of your complaints. Read the instructions first . Then make a list of your complaints and describe each of them according to the instructions.
C O N F I D E N T I A L
Date :
Name:
(Begin with surname)
Address :
Telephone : Residence :
Office :
Age :
Sex: Male / Female
Vegetarian / Non Veg. / Egg Veg.
Single / Married / Divorced / Widowed
Occupation (Nature of work):
Education:
Referred to us by:
PREVIOUS DISEASES & DRUGS USED
Every disease, poisoning, drug or accident leaves its mark and remains as a weak point in the system, much more than we imagine . Homoeopathic treatment takes into account all these details of the past and thus removes all the weak points. Thus your body is strengthened. That is why it is necessary for us to know about all the ailments you have suffered from in the past and the treatments you have taken.
In the list below, circle around names of ALL major illnesses so far suffered and on the next page give its relevant details.
Typhoid
Cholera
Food Poisoning
Worms
Diarrhoea
Dysentery
Measles
German measles
Chicken-pox
Small-pox
Mumps
Whooping cough
Malaria
Jaundice
Any Liver
Spleen or
Gall Bladder
Disease
Miscarriage .
Abortion
Currettings
Sickness during
Pregnancy etc.
Prolapse of uterus
Malnutrition
Rickets
Rheumatism
Backache
Any venereal
Disease like
Syphilis
Gonorrhoea etc.
Any heart trouble ,
Blood pressure ,
Giddiness
Nephritis (Kidney or urine trouble)
Diabetes etc.
Prostate trouble
Any operation such as Tonsils , Abdomen , Appendix , Hernia , Piles, Uterus , Renal Stone , Gall Stones, Phimosis , Hydrocele , Cataract etc. Mode of anaesthesia : general –local
Diphtheria, Septic Tonsils , Adenoids Recurrent infections – Sinusitis Bronchitis –Eosinophilia Cold 0-Fever-Chill . Pneumonia Asthma –Pleurisy—T.B.
Any serious shock , grief , disappointments, fright , mental upset , depression or nervous break down
Chronic Headaches, Numbness , Cramps, Fits , Convulsions Polio, Paralysis etc. Meningitis –Any Lumbar puncture done.
Any major accident or injury to body or head. Any occasion of unconsciousness
Any major bleeding from any part of the body.
Skin diseases like Pimples , Boils, Carbuncles, Ringworms, Fungus, Scabies , Eczema.
Ulcers on any part of the body.
Diseases suffered from
Approximate Age
Duration
Whether you completely recovered
Medicines & treatment taken
Any other particulars
Any extra remarks of information :
Mention any drugs , tonics , stimulants etc. That have been used by you at any time in life.
FAMILY INFORMATION
List of major diseases
Anaemia
Cancer
Diabetes
Insanity
Rheumatism
T. B. /Pleurisy
Leprosy
Epilepsy/fits
Bleeding tendency
Urticaria
Eczema
Asthma
Paralysis
Hypertension
Heart trouble
Kidney disease
Liver disease etc.
Relationship
Alive /dead
Age
Diseases
Cause of death
Paternal Grand Father
Paternal Grand Mother
Maternal Grand Father
Maternal Grand Mother
Father
Mother
Diseases Suffered
Paternal Uncles
Paternal Aunts
Maternal Uncles
Maternal Aunts
Cousin Brother & Sister on Father’s side
Cousin Brother & Sister on Mother’s side
Did any of your relatives have trouble similar to yours
* How many brother –sister are you? (including those who died , if any).
Provide information about them in the table below. Indicate your position by writing ‘SELF’.
SR.NO
Brother /Sister
Alive /Dead
Age
Diseases suffered
1.
2.
3.
4.
5.
6.
7.
8.
PERSONAL HISTORY
*About your birth
Did your mother have any problem during pregnancy ?
Did She take drugs during pregnancy ?What were they?
Was there any difficulty about your birth ? Give details.
*At what age did you start.
Teething
Urine Control
Bed wetting etc.
Sitting
Standing
Eating indigestibles Like chalk , lime ,earth. Slate-pen
Walking
Speaking
Any other problem about Your growth & development
Tick mark (X) if any animal bites such as :
Dog
Rat
Snake
Scorpion
Mention if any other :
Did you take anti-rabies or anti –venom or any other treatment ?
*Vaccination & Inoculations :
Indicate number of times you were vaccinated for the following :
Small pox
Polio
Cholera
Measles
Triple
B.C.G.
Typhoid
Tetanus
Was there any reaction or particular trouble after any of above vaccinations of inocculations ?
Give details:
(if married) How is the health of your husband /wife :
*Number of children living and dead . If dead , state causes :
Mention ages of children and their condition of health.
Child’s name
Male/Female
Age
Diseases Suffered
Any abortions , miscarriages or still birth ?
Your Habits
How much
Smoking
Snuff
Chewing Tobacco
Alcohol
Tea
Sleeping Pills
Laxatives /Purgatives
Any other
Main complaints and other associated troubles: (and detailed history of the present illness, The onset and course with dates).
ORIGIN OF CAUSE : Can you trace the origin illness to any particular circumstance accident , illness, incident or mental upset ? (e.g. Shock , worry , errors in diet ,overexertion , exposure to cold , heat etc.)?
APPETITE AND THIRST
How is your appetite?
When are you hungry?
What happens if you have to remain hungry for long?
How fast do you eat?
How much thirst do you have?
Any particular time are you specially thirsty ?
Do you feel any change in your taste and feeling in your mouth?
Please Put one tick (X) if you Like / Dislike the food or if the food disagrees. Put two tick mark(X X) if you strongly Like / Dislike the food or if the food strongly disagrees.
Like
Dislike
Disagrees
Like
Dislike
Disagrees
Bitter
Eggs
Salt extra
Spicy food
Sweet
Meat
Sour
Fish
Bread
Cabbages
Butter
Onions
Fats
Warm food/drink
Milk
Cold food/drink
Coffee
Fruits
Mud/chalk
Anything else
STOOL
Do you have any problem regarding your stools?
When and how many times a day do you pass stools ?
When is it urgent?
Do you have any problem about bowel movements?
Do you have to strain for stool? Even if soft?
Do you have belching or passing gas? Describe its character.
How do you feel after passing gas up or down?
URINATION & URINE
Any problem about urine ?
Any strong smell ? Like what?
Do you have any trouble before , during and after passing urine?
Any difficulty about the flow ? Slow to start , interrupted , feeble dribbling etc.?
Any involuntary urination? When ?
SWEAT/PERSPIRATION-FEVER-CHILL
How much do you sweat ?
Where and on what part do you sweat most?
Do you perspire on the palms or soles?
Is the sweat warm , cold , clammy, sticky, musty, greasy, stiffens the linen etc.?
What is the smell like ?e.g. foul , pungent, sour , urinous.
What colour does it stain the clothing ?
Is the stain easy to wash off or difficult ?
Any symptoms after sweating ?
When do you get fever or chill ?
What brings it on ?
Do you experience any sense of heat or cold in
Any part of your body at any particular time?
CHEST-HEART – COLD – COUGH
Do you catch cold often ?if so, how?
Describe the symptoms ,nature of discharge etc.
Is there any trouble with your CHEST or HEART ?
Is there any trouble with your voice or speech?
Is there any difficulty in breathing ?
Do you have cough ?
Is it more at any particular time?
SEXUAL SPHERE (GENERAL)
Any excessive indulgence in sex in past and present ? Any effect on your health ?
How do you feel after sexual intercourse?
Any particular feeling or symptoms appear before , during and after sexual intercourse?
Do you suffer from any sexual disturbance ?
(Homosexual inclination etc.?)
Any habit like (masturbation etc.) in past as well as present? How often?
Did you suffer from any Venereal disease ?
Syphilis ? Gonorrhoea ?
Do you have increased desire or decreased desire for sex?
What is the method you use for family planning?
FOR MEN
Any difficulty in erection ?
Wanted erection ? unwanted erection ?
Weak erection ? Failing erection ? Describe.?
Any other trouble in sex ? Describe in details
FOR WOMEN
Menses : How are the periods ;regular or irregular?
At what age did it start?
Was there any trouble then?
Mention number of days of flow.
Menstrual flow : Is there any change now in quantity , colour , smell or consistency?
Are the stains difficult to wash ?
Have you noticed any variation in quality and quantity of flow during menses?
How and when?
Do you suffer in any way before , during or after menses ?If so, describe:
What symptoms did you suffer during menopause ?
Do you feel the internal parts coming down?
Is there any white discharge?
If so , mention the nature , colour , consistency and smell of discharge.
When and under what circumstances is it more or less .
Has the discharge any relation to menses?
What is the effect of this discharge on your general feeling ? or any of your symptoms ?
Any itching , excoriation etc. due to discharge?
Do you pass any gas from vagina ?
Any trouble with breasts?
ANY COMPLAINTS ABOUT :
VERTIGO- Do you have giddiness – vertigo?
FAINTNESS: Do you ever feel faint?
HEAD: Do you get headaches?
EYES & Vision:
EARS & sense of hearing :
NOSE & sense of smell:
FACE & Facial expression:
MOUTH & sense of taste:
About LIPS, MOUTH, TONGUE etc. :
TEETH, GUMS e.g. carious teeth m bleeding gums.
Swollen gums:
LIPS:cracked , peeling of skin etc.
THROAT (including tonsils) :
Any difficulty in swallowing?
Do you have any trouble in your BACK , LIMBS OR JOINTS? Describe in details:
If you have any pains , do they shift?
In what direction do they extend ?
Is there any complaint of skin : such as itching , eruptions , ulcers , warts, corns, peeling etc.? (Describe its name )
Any change in colour of the skin or spots on any part of the body ?
Is there any complaint or abnormality of the NAILS or skin around ?
Is there any complaint with the HAIR such as falling , graying, dandruff, dryness, oily, poor excessive or unusual growth ?
Do wounds heal slowly ?
Form keloid? Do wounds tend to form pus?
Have you a tendency to bleed?
Are your troubles one sided ? Which one?
Or more on one side?
Do they proceed from one to the other side ?
Or do they alternate or shift?
Is there any trembling ? When?
Is there any sense of weakness ? Where?
When is it more or less?
Is it in any particular part of the body?
FACTORS THAT AFFECT YOU
Below are a list of things that you are exposed to. Each of these factors may affect you in a particular way . Please write in what way you are affected by each of the following . Do you feel worse or better in any way from each of the factors. In what way do they affect you.
For instance take the factor "sun". Suppose by going in the sun you get a headache, then write "Headache " opposite to "sun".
Take another example . if in hot weather you feel uneasy, then write "Uneasy" opposite to "Hot Weather " in the column.
In this way write the effect of each factor on you. Especially write the effect each factor has on your main complaints . For instance if your main complaint is asthma and this is worse when lying on the back then opposite to "lying on the back "write "asthma becomes worse"
Sometimes one factor may make you feel worse in some respect, and better in some other respect, For instance cold air may cause headache but headache but make you feel better in general. If this is so, please mention this difference clearly.
This section is most important. Do not go through it hurriedly . Think carefully about the effect of each factor before you write.
Effect
Effect
Hot weather
Walking
Cold weather
Running
Rainy weather
Climbing stairs
Cloudy weather
Going downstairs
Change of season
Riding in bus, car etc.
Thunder –storm
Lying
Covering
Lying on back
Warm bath
Lying on left side
Sun
Lying on right side
Cold bathing
Lying on abdomen
Lying with head low
Drinking
Sitting
After sexual intercourse
Sitting erect
Dust
Standing
Smoke
Looking up
Touch
Looking down
Pressure
Looking from high places
Massage
Looking at moving object
Tight clothes
Noise
Before sleep
Sudden noise
During sleep
Music
After sleep
Light
After afternoon nap
Strong smells
Loss of sleep
When constipated
Before stools
Before urine
During stools
During urine
After stools
After urine
Coughing
Before menses
Sneezing
During menses
Laughing
After menses
Talking
After Sweating
Reading
When Fasting
Writing
After eating
Stooping
Before important engagement
Passing gas
Before exams
After hair cut
When angry
Combing hair
When worried
Brushing teeth
When sad
Moonlight
After weeping
Opening the mouth
Consolation /sympathy
Smoking
In a crowd
Hanging the limbs
In a closed room
Hanging the arms
When thinking of illness
Near sea
Full noon /new moon
Shaving
Morning
Stretching
Afternoon
Swallowing
Evening
Listening to others talk
Night
Vomiting
Bathing
Yawning
Draft air
Moving the eyes
Biting or chewing
Opening the eyes
Blowing nose
Closing the eyes
When alone
Getting feet wet
In company
Over eating
Physical exertion
Working in water
Belching
Fanning
MIND
It is now universally acknowledged that your mind has tremendous influence on your body . For giving proper treatment it is necessary for us to understand your emotional and intellectual nature . We can thus treat you as a whole.
In order to understand you we will be asking certain questions . Answer them freely, carefully , and completely. This information will help us much in giving you the correct remedy . Also such a remedy will help improve your mental make up.
Answer freely. Answer frankly. Answer completely.
Are you anxious ? About which matters?
Are you fearful of anything such as
Animals people being alone, darkness,
death, diseases, robbers, sudden noises ,
thunder, of the future , of something
unknown , high places, etc.?
Are you doubtful or suspicious ? Of what?
What are you jealous about?
Of whom ? From what symptoms do you suffer when jealous?
In which matters are you impatient?
Hurried?
How long do you remember hurts caused to you by others?
How much revengeful are you?
What are you proud of? Does your pride get easily hurt?
Depressed , Brooding , etc.?
Do you ever become suicidal? When ?
If so in what manner do you contemplate to end your life ?
Even then , are you afraid of dying ?
When are you cheerful?
Are you sexual-minded?
Any unwanted thoughts any time ?
What are they?
Have you any imaginary sensations or fears?
Do you hear voices , or that you are called ,or anything else in this line keeps on occurring in your mind unduly?
How is your memory ?
For what is it poor? e.g. names, places , faces, what you have read, etc.
Do you weep easily?
What makes you weep?
How do you feel after weeping ?
How do you feel if someone offers sympathy and consolation?
Are you easily irritated?
What makes you angry?
What bodily symptoms do you develop
When angry? e.g. trembling ,sweating etc.
Do you like company ?or like to remain alone?
How seriously are you affected by disorder and uncleanliness in your surrounding ?
What are the greatest griefs that you have gone through in your life?
What are the greatest joys that you have had in life?
What activities you deeply like?
Are there any matters which you deeply dislike?
In your opinion, which aspects of your mind
and moods are not agreeable to you . Inspite of
your awareness and maturity , are you
unable to change these these aspects?
Give a clear cut picture of your situation in life and your relationship
With each of your family members, friends and associates in work .
How does the future look to you?
Are you worried or unhappy over any and personal, domestic, economical , social or any other condition?
If so describe in detail:
S L E E P
Describe your posture in sleep.
On the back , side, abdomen etc.
Are you able to sleep in any position ?
In which position you can’t sleep?
During sleep do you:
Snore? Grind teeth?
Dribble saliva? Sweat ?
Keep eyes or mouth open?
Walk? Talk? Moan? Weep ?
Become restless? Wake up with a jerk?
Describe if anything else is unusual about your sleep: (sleepy, sleeplessness,etc. . if so when)
How much do you cover?
Do you have to uncover any parts?
Circle types of dream that you have
Animal
Cats-dogs
Horse
Wild animals
Snakes
Robbers
Thieves
Anxious
Fearful
Ghosts
Travelling
Riding
Flying
Swimming
drowning
Houses
Fruits
Trees
Water
Snow
Death, Whose?
Dead bodies
Dead person
Parts of Body
Suicide
Being Hungry
Being Thirsty
Drinking
Eating
Fire
Lightning
Storm
Rain
Accidents
Falling
Shooting
Wars
Talking
Singing
Dancing
Pleasant
Business
Money
Day’s work
Forgotten work
Vomiting
Passing stool
Urinating
Blood – bleeding
Excrements / soiling
Romantic
Sexual pleasure
Rape
nakedness
Pain
Illness
Sickness
Mutilations
Praying
Religious
Temple
Church
God
Failure /exams
Unsuccessful efforts for what
Missing train
Being unprepared
Grief
Weeping
Vexation
Quarrels
Jealousy
Insults
Police
Imprisonment
Crime
Murder
Killing
Poison
Misfortunes
Insecurity
Danger
Being pursued
By whom?
-for what ?
If any other, specify
In the space below:
Of people
Children
Parties
Feasts
Marriage
Of events
Remote
Recent
Future
Prophetic
Physical Exertion
Mental Exertion
Fatigue
Coloured
Multi-Coloured
FOR CHILDREN or YOU AS A CHILD
(IN CASE OF ADULTS )
1) Please tick mark once (X) if the child or you as child had any of the following qualities: Tick mark twice (XX) if they are more intense :
Tick Here
Tick here
Obstinacy
Unusual fears
Temper tantrums
Shyness
Disobedience
Unusual attachments (to whom)
Aggression
Habits like :-
Hyperactivity
Biting nails
Destructiveness
Thumb –sucking
Courage
Picking and playing with
Possessiveness
(a) mother’s body parts
Competition-winning spirit
(b)shawls , handkerchieves
Sibling jealousy
(c) anything else
Any special skills
Religious
Unusual desires (for what )
Dullness of memory
Boasting
Slowness (in what)
Stealing
Laziness /Indolence
Telling lies
Sensitive/Emotional
2) Please write in detail, if the mother suffered from any physical or emotional stress during pregnancy .Also describe the dreams the mother got during pregnancy.
3) Please describe any other aspects you feel are striking about the child .
4) Describe one incident from the child’s life when he/she very upset.
HOW TO DESCRIBE YOUR COMPLAINTS
In homoeopathy, prescription is based on precise details of various symptoms from which you suffer. To tell or write to a homoeopathic physician "I have a headache ", " an eruption ", " a cough", would not be enough. If you inform him "I have headache with sharp shooting pains in the left side of the head and temple ", these pains always come on when the slightest cold air strikes the head , the pains wailing about , or when the head becomes cool ". then only you have given all the information required for making a good homoeopathic prescription. The success of the prescription depends, largely on how detailed is your description of the symptoms
We require the following details about your symptoms.
LOCATION : Please give the exact location of sensation , pain or eruption. Also describe where the pain or sensation spreads. Please use the figure on page 23 to indicate location.
SENSATION : Express the type of sensation or the pain that you get in your own words however simple or funny it may seem. You may have a sensation that a mouse is crawling or the heart was grasped by an iron hand or you may have a pain which is cutting, burning jerking , pressing . Express the sensation or pain as it feels to you.
WHAT MAKES YOU WORSE OR BETTER : Many factors are likely to influence your trouble . Some factors may cause the trouble to increase and some factors may relieve the trouble . A detailed list of the factors is given on pages 14 to 16 . Please refer to when describing each of your troubles and indicate which factors make the complaint better or worse.
DISCHARGES : You may have a discharge from ulcers , fistula, eruptions , the skin , lungs, eyes , nose , ears , mouth , private parts, etc. Please describe your discharge under the following aspects .
· The quantity and the time or condition under which the quantity varies i.e. when is it better or worse , increases or decreases ?
· The consistency : Is it thin or thick , stringy or clotted ?
· Is it like jelly, white of an egg, like water , sticky forming a scab etc. ?
· The odour , what does it remind you of ?
· Does it make the parts sore, and in what way?
Please mark in the below figure, the locations of your trouble and write the exact sensation or type of pain you experience at those spots. For example if you have throbbing pain on the right side of you head please mark as shown
clip_image002
clip_image003
IN THE FOLLOWING PAGES PLEASE DESCRIBE EACH OF YOUR COMPLAINTS IN DETAILS IN THE MANNER DESCRIBED ON PAGE 22.
COMPLAINT NO.
WHERE IS THE TROUBLE
WHAT EXACTLY DO YOU FEEL OR HAVE THERE
WHAT ARE THE FACTORS THAT MAKE THIS TROUBLE BETTER OR WORSE
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Labels: case taking format, Clinical, homeopathy
HOMEOPATHIC CASE-TAKING FOR CHILDREN
Notes from Robin Murphy's Pediatric Seminar
April 9 - 10, 1983
I. OBSERVE
A. Eyes: softness, sharpness, fear, hysterical, delicate, evil, irritable, dissatisfied,
pain...
B. Bodies: restless, hyper, slow, timid, aggressive, outgoing, obedient or disobedient,
how sensitive? Shy? Clumsy? Coordinated?
II. Differentiate: Is this a first-aid, acute, or chronic case/problem at this time?
III. Generals: Diet, sleep, weather, mental-emotional state, misc.
IV. Behavioral analysis
A. Playing:
1. Alone or with others?
a) leaders or followers?
b) plays with younger children or peers?
c) imaginative, builders, etc.
2. How does he/she play with animals and toys?
a) obsessed with blanket or toy?
b) rough, break things?
c) fear or love animals?
3. How competitive or aggressive?
4. Reaction to physical pain, scrapes, bumps, etc.
B. Independent vs. dependent
1. How responsible?
2. How handle being alone?
3. Reaction if doesn't get what he/she wants.
4. Reaction to strangers.
C. Patterns
1. Sleep
2. Feeding time, playing time, sleep time.
V. Developmental History
A. Learning to talk, walk, language, comprehension, musculoskeletal development.
B. Toilet training: how child went through it.
C. How was the pregnancy?
D. Family hx: TB, GC, CA
VI. Mental-Emotional State
A. Sensitivity to pain, injury, noise, touch, being carried.
B. Better or worse attention/consolation?
C. Sensitivity to other's pain, to parents fighting, to weather, movies, sad stories, how
sensitive is their imagination?
D. Easily startled?
E. Family dynamics
1. How does he/she get along with siblings? Parents?
2. Reaction to new siblings.
3. Divorce
4. Military family, moved many times?
5. Alcoholism, drugs, tension in family?
6. Motivated by fear? Do parents threaten, frighten, humiliate?
Fear of punishment by God?
7. Is the child compared with a sibling or parent, forced to live up to parent's
role expectations?
VII. Family economics: adequate diet, nutritional status.
VIII. Story about the child. (Usually a chronic constitutional or acute case can be taken directly
from a child aged 6 - 8 or older.)
A. Reactions to griefs, deaths, frights.
B. Mother's description of the pregnancy, labor, and birth.
C. Health and family history.
IX. Objective symptoms
A. Facial expression: observe pupils. How aware is the child of his or her environment?
B. Skin
1. Dry, moist, cool, warm.
2. Healthy or unhealthy?
3. Touch the chest, abdomen, forehead, hands and feet.
Note temp, character, moisture, etc.
C. Sweat: amount, parts that sweat, odor.
D. Moles, warts, birthmarks.
E. Tongue: color, furry or smooth?
F. Breath: Offensive?
G. Reaction to stimuli: light in eyes, noise, jar, pinch.
H. Urine and stool.
I. Strength: check grasp, posture. How does the child hold her head up?
X. Fears: Monsters, ghosts, strangers, the dark, movies, being alone, dogs, death, fears
something will happen to the parents, something is creeping out of every corner,
evil spirits, falling, noises
XI. Sleep: Insomnia: due to pain, fear, over-excitement, want attention, overactive mind?
XII. Food cravings and aversions: including thirst
XIII. Times, modalities for symptoms. CASE TAKING FORMAT FOR ADULTS & CHILDREN
CASE - RECORD
PLEASE READ THIS FIRST BEFORE FILLING THIS FORM
You have get well. We are here to select the best possible medicine for you .In order to do that, we depend on your co-operation. HOMOEOPATHIC MEDICINE IS MAINLY SELECTED ON THE SYMPTOMS YOU GIVE US. If we are to make a successful prescription, we must know all the details of your sickness. We must also understand all the features that belong to you as an individual. This includes your reactions to various factors, your past and family history and your mental make up.
This information enables us to selection the remedy that removes your sickness. The medicine also makes you well as a whole person.
In order to find out all about you, we shall be asking you many questions. Each one of these questions has a definite meaning and significance for us. There is not a single questions that is useless. Even something that your may think is not connected with your trouble, may be the most important factor in deciding the correct homoeopathic medicine. That is why you must be free and frank and give us the fullest possible information on each point. Please read each question carefully, think and if necessary, consult someone close to you and then answer completely. Do not keep anything back. Remember, whatever you tell us will remain absolutely confidential.
THIS QUESTIONNAIRE FORM HAS 8 PARTS :
1. About your past illnesses and family illnesses. Please take time to answer this part with the help of your family members before coming to us.
2. History of your present illness.
3. About all the parts of your body.
4. Deals with the factors that affect your health.. Please think carefully about each of the factors mentioned and write what specific effects they have on you.
5. About your mental state and your emotional nature . Please write in this part about your situation in life and about all the things that are bothering you. Be totally frank and open.
6. About your sleep and dreams .
7. For children or you as a child .
8. In this part you are given instructions on how to report each of your complaints. Read the instructions first . Then make a list of your complaints and describe each of them according to the instructions.
C O N F I D E N T I A L
Date :
Name:
(Begin with surname)
Address :
Telephone : Residence :
Office :
Age :
Sex: Male / Female
Vegetarian / Non Veg. / Egg Veg.
Single / Married / Divorced / Widowed
Occupation (Nature of work):
Education:
Referred to us by:
PREVIOUS DISEASES & DRUGS USED
Every disease, poisoning, drug or accident leaves its mark and remains as a weak point in the system, much more than we imagine . Homoeopathic treatment takes into account all these details of the past and thus removes all the weak points. Thus your body is strengthened. That is why it is necessary for us to know about all the ailments you have suffered from in the past and the treatments you have taken.
In the list below, circle around names of ALL major illnesses so far suffered and on the next page give its relevant details.
Typhoid
Cholera
Food Poisoning
Worms
Diarrhoea
Dysentery
Measles
German measles
Chicken-pox
Small-pox
Mumps
Whooping cough
Malaria
Jaundice
Any Liver
Spleen or
Gall Bladder
Disease
Miscarriage .
Abortion
Currettings
Sickness during
Pregnancy etc.
Prolapse of uterus
Malnutrition
Rickets
Rheumatism
Backache
Any venereal
Disease like
Syphilis
Gonorrhoea etc.
Any heart trouble ,
Blood pressure ,
Giddiness
Nephritis (Kidney or urine trouble)
Diabetes etc.
Prostate trouble
Any operation such as Tonsils , Abdomen , Appendix , Hernia , Piles, Uterus , Renal Stone , Gall Stones, Phimosis , Hydrocele , Cataract etc. Mode of anaesthesia : general –local
Diphtheria, Septic Tonsils , Adenoids Recurrent infections – Sinusitis Bronchitis –Eosinophilia Cold 0-Fever-Chill . Pneumonia Asthma –Pleurisy—T.B.
Any serious shock , grief , disappointments, fright , mental upset , depression or nervous break down
Chronic Headaches, Numbness , Cramps, Fits , Convulsions Polio, Paralysis etc. Meningitis –Any Lumbar puncture done.
Any major accident or injury to body or head. Any occasion of unconsciousness
Any major bleeding from any part of the body.
Skin diseases like Pimples , Boils, Carbuncles, Ringworms, Fungus, Scabies , Eczema.
Ulcers on any part of the body.
Diseases suffered from
Approximate Age
Duration
Whether you completely recovered
Medicines & treatment taken
Any other particulars
Any extra remarks of information :
Mention any drugs , tonics , stimulants etc. That have been used by you at any time in life.
FAMILY INFORMATION
List of major diseases
Anaemia
Cancer
Diabetes
Insanity
Rheumatism
T. B. /Pleurisy
Leprosy
Epilepsy/fits
Bleeding tendency
Urticaria
Eczema
Asthma
Paralysis
Hypertension
Heart trouble
Kidney disease
Liver disease etc.
Relationship
Alive /dead
Age
Diseases
Cause of death
Paternal Grand Father
Paternal Grand Mother
Maternal Grand Father
Maternal Grand Mother
Father
Mother
Diseases Suffered
Paternal Uncles
Paternal Aunts
Maternal Uncles
Maternal Aunts
Cousin Brother & Sister on Father’s side
Cousin Brother & Sister on Mother’s side
Did any of your relatives have trouble similar to yours
* How many brother –sister are you? (including those who died , if any).
Provide information about them in the table below. Indicate your position by writing ‘SELF’.
SR.NO
Brother /Sister
Alive /Dead
Age
Diseases suffered
1.
2.
3.
4.
5.
6.
7.
8.
PERSONAL HISTORY
*About your birth
Did your mother have any problem during pregnancy ?
Did She take drugs during pregnancy ?What were they?
Was there any difficulty about your birth ? Give details.
*At what age did you start.
Teething
Urine Control
Bed wetting etc.
Sitting
Standing
Eating indigestibles Like chalk , lime ,earth. Slate-pen
Walking
Speaking
Any other problem about Your growth & development
Tick mark (X) if any animal bites such as :
Dog
Rat
Snake
Scorpion
Mention if any other :
Did you take anti-rabies or anti –venom or any other treatment ?
*Vaccination & Inoculations :
Indicate number of times you were vaccinated for the following :
Small pox
Polio
Cholera
Measles
Triple
B.C.G.
Typhoid
Tetanus
Was there any reaction or particular trouble after any of above vaccinations of inocculations ?
Give details:
(if married) How is the health of your husband /wife :
*Number of children living and dead . If dead , state causes :
Mention ages of children and their condition of health.
Child’s name
Male/Female
Age
Diseases Suffered
Any abortions , miscarriages or still birth ?
Your Habits
How much
Smoking
Snuff
Chewing Tobacco
Alcohol
Tea
Sleeping Pills
Laxatives /Purgatives
Any other
Main complaints and other associated troubles: (and detailed history of the present illness, The onset and course with dates).
ORIGIN OF CAUSE : Can you trace the origin illness to any particular circumstance accident , illness, incident or mental upset ? (e.g. Shock , worry , errors in diet ,overexertion , exposure to cold , heat etc.)?
APPETITE AND THIRST
How is your appetite?
When are you hungry?
What happens if you have to remain hungry for long?
How fast do you eat?
How much thirst do you have?
Any particular time are you specially thirsty ?
Do you feel any change in your taste and feeling in your mouth?
Please Put one tick (X) if you Like / Dislike the food or if the food disagrees. Put two tick mark(X X) if you strongly Like / Dislike the food or if the food strongly disagrees.
Like
Dislike
Disagrees
Like
Dislike
Disagrees
Bitter
Eggs
Salt extra
Spicy food
Sweet
Meat
Sour
Fish
Bread
Cabbages
Butter
Onions
Fats
Warm food/drink
Milk
Cold food/drink
Coffee
Fruits
Mud/chalk
Anything else
STOOL
Do you have any problem regarding your stools?
When and how many times a day do you pass stools ?
When is it urgent?
Do you have any problem about bowel movements?
Do you have to strain for stool? Even if soft?
Do you have belching or passing gas? Describe its character.
How do you feel after passing gas up or down?
URINATION & URINE
Any problem about urine ?
Any strong smell ? Like what?
Do you have any trouble before , during and after passing urine?
Any difficulty about the flow ? Slow to start , interrupted , feeble dribbling etc.?
Any involuntary urination? When ?
SWEAT/PERSPIRATION-FEVER-CHILL
How much do you sweat ?
Where and on what part do you sweat most?
Do you perspire on the palms or soles?
Is the sweat warm , cold , clammy, sticky, musty, greasy, stiffens the linen etc.?
What is the smell like ?e.g. foul , pungent, sour , urinous.
What colour does it stain the clothing ?
Is the stain easy to wash off or difficult ?
Any symptoms after sweating ?
When do you get fever or chill ?
What brings it on ?
Do you experience any sense of heat or cold in
Any part of your body at any particular time?
CHEST-HEART – COLD – COUGH
Do you catch cold often ?if so, how?
Describe the symptoms ,nature of discharge etc.
Is there any trouble with your CHEST or HEART ?
Is there any trouble with your voice or speech?
Is there any difficulty in breathing ?
Do you have cough ?
Is it more at any particular time?
SEXUAL SPHERE (GENERAL)
Any excessive indulgence in sex in past and present ? Any effect on your health ?
How do you feel after sexual intercourse?
Any particular feeling or symptoms appear before , during and after sexual intercourse?
Do you suffer from any sexual disturbance ?
(Homosexual inclination etc.?)
Any habit like (masturbation etc.) in past as well as present? How often?
Did you suffer from any Venereal disease ?
Syphilis ? Gonorrhoea ?
Do you have increased desire or decreased desire for sex?
What is the method you use for family planning?
FOR MEN
Any difficulty in erection ?
Wanted erection ? unwanted erection ?
Weak erection ? Failing erection ? Describe.?
Any other trouble in sex ? Describe in details
FOR WOMEN
Menses : How are the periods ;regular or irregular?
At what age did it start?
Was there any trouble then?
Mention number of days of flow.
Menstrual flow : Is there any change now in quantity , colour , smell or consistency?
Are the stains difficult to wash ?
Have you noticed any variation in quality and quantity of flow during menses?
How and when?
Do you suffer in any way before , during or after menses ?If so, describe:
What symptoms did you suffer during menopause ?
Do you feel the internal parts coming down?
Is there any white discharge?
If so , mention the nature , colour , consistency and smell of discharge.
When and under what circumstances is it more or less .
Has the discharge any relation to menses?
What is the effect of this discharge on your general feeling ? or any of your symptoms ?
Any itching , excoriation etc. due to discharge?
Do you pass any gas from vagina ?
Any trouble with breasts?
ANY COMPLAINTS ABOUT :
VERTIGO- Do you have giddiness – vertigo?
FAINTNESS: Do you ever feel faint?
HEAD: Do you get headaches?
EYES & Vision:
EARS & sense of hearing :
NOSE & sense of smell:
FACE & Facial expression:
MOUTH & sense of taste:
About LIPS, MOUTH, TONGUE etc. :
TEETH, GUMS e.g. carious teeth m bleeding gums.
Swollen gums:
LIPS:cracked , peeling of skin etc.
THROAT (including tonsils) :
Any difficulty in swallowing?
Do you have any trouble in your BACK , LIMBS OR JOINTS? Describe in details:
If you have any pains , do they shift?
In what direction do they extend ?
Is there any complaint of skin : such as itching , eruptions , ulcers , warts, corns, peeling etc.? (Describe its name )
Any change in colour of the skin or spots on any part of the body ?
Is there any complaint or abnormality of the NAILS or skin around ?
Is there any complaint with the HAIR such as falling , graying, dandruff, dryness, oily, poor excessive or unusual growth ?
Do wounds heal slowly ?
Form keloid? Do wounds tend to form pus?
Have you a tendency to bleed?
Are your troubles one sided ? Which one?
Or more on one side?
Do they proceed from one to the other side ?
Or do they alternate or shift?
Is there any trembling ? When?
Is there any sense of weakness ? Where?
When is it more or less?
Is it in any particular part of the body?
FACTORS THAT AFFECT YOU
Below are a list of things that you are exposed to. Each of these factors may affect you in a particular way . Please write in what way you are affected by each of the following . Do you feel worse or better in any way from each of the factors. In what way do they affect you.
For instance take the factor "sun". Suppose by going in the sun you get a headache, then write "Headache " opposite to "sun".
Take another example . if in hot weather you feel uneasy, then write "Uneasy" opposite to "Hot Weather " in the column.
In this way write the effect of each factor on you. Especially write the effect each factor has on your main complaints . For instance if your main complaint is asthma and this is worse when lying on the back then opposite to "lying on the back "write "asthma becomes worse"
Sometimes one factor may make you feel worse in some respect, and better in some other respect, For instance cold air may cause headache but headache but make you feel better in general. If this is so, please mention this difference clearly.
This section is most important. Do not go through it hurriedly . Think carefully about the effect of each factor before you write.
Effect
Effect
Hot weather
Walking
Cold weather
Running
Rainy weather
Climbing stairs
Cloudy weather
Going downstairs
Change of season
Riding in bus, car etc.
Thunder –storm
Lying
Covering
Lying on back
Warm bath
Lying on left side
Sun
Lying on right side
Cold bathing
Lying on abdomen
Lying with head low
Drinking
Sitting
After sexual intercourse
Sitting erect
Dust
Standing
Smoke
Looking up
Touch
Looking down
Pressure
Looking from high places
Massage
Looking at moving object
Tight clothes
Noise
Before sleep
Sudden noise
During sleep
Music
After sleep
Light
After afternoon nap
Strong smells
Loss of sleep
When constipated
Before stools
Before urine
During stools
During urine
After stools
After urine
Coughing
Before menses
Sneezing
During menses
Laughing
After menses
Talking
After Sweating
Reading
When Fasting
Writing
After eating
Stooping
Before important engagement
Passing gas
Before exams
After hair cut
When angry
Combing hair
When worried
Brushing teeth
When sad
Moonlight
After weeping
Opening the mouth
Consolation /sympathy
Smoking
In a crowd
Hanging the limbs
In a closed room
Hanging the arms
When thinking of illness
Near sea
Full noon /new moon
Shaving
Morning
Stretching
Afternoon
Swallowing
Evening
Listening to others talk
Night
Vomiting
Bathing
Yawning
Draft air
Moving the eyes
Biting or chewing
Opening the eyes
Blowing nose
Closing the eyes
When alone
Getting feet wet
In company
Over eating
Physical exertion
Working in water
Belching
Fanning
MIND
It is now universally acknowledged that your mind has tremendous influence on your body . For giving proper treatment it is necessary for us to understand your emotional and intellectual nature . We can thus treat you as a whole.
In order to understand you we will be asking certain questions . Answer them freely, carefully , and completely. This information will help us much in giving you the correct remedy . Also such a remedy will help improve your mental make up.
Answer freely. Answer frankly. Answer completely.
Are you anxious ? About which matters?
Are you fearful of anything such as
Animals people being alone, darkness,
death, diseases, robbers, sudden noises ,
thunder, of the future , of something
unknown , high places, etc.?
Are you doubtful or suspicious ? Of what?
What are you jealous about?
Of whom ? From what symptoms do you suffer when jealous?
In which matters are you impatient?
Hurried?
How long do you remember hurts caused to you by others?
How much revengeful are you?
What are you proud of? Does your pride get easily hurt?
Depressed , Brooding , etc.?
Do you ever become suicidal? When ?
If so in what manner do you contemplate to end your life ?
Even then , are you afraid of dying ?
When are you cheerful?
Are you sexual-minded?
Any unwanted thoughts any time ?
What are they?
Have you any imaginary sensations or fears?
Do you hear voices , or that you are called ,or anything else in this line keeps on occurring in your mind unduly?
How is your memory ?
For what is it poor? e.g. names, places , faces, what you have read, etc.
Do you weep easily?
What makes you weep?
How do you feel after weeping ?
How do you feel if someone offers sympathy and consolation?
Are you easily irritated?
What makes you angry?
What bodily symptoms do you develop
When angry? e.g. trembling ,sweating etc.
Do you like company ?or like to remain alone?
How seriously are you affected by disorder and uncleanliness in your surrounding ?
What are the greatest griefs that you have gone through in your life?
What are the greatest joys that you have had in life?
What activities you deeply like?
Are there any matters which you deeply dislike?
In your opinion, which aspects of your mind
and moods are not agreeable to you . Inspite of
your awareness and maturity , are you
unable to change these these aspects?
Give a clear cut picture of your situation in life and your relationship
With each of your family members, friends and associates in work .
How does the future look to you?
Are you worried or unhappy over any and personal, domestic, economical , social or any other condition?
If so describe in detail:
S L E E P
Describe your posture in sleep.
On the back , side, abdomen etc.
Are you able to sleep in any position ?
In which position you can’t sleep?
During sleep do you:
Snore? Grind teeth?
Dribble saliva? Sweat ?
Keep eyes or mouth open?
Walk? Talk? Moan? Weep ?
Become restless? Wake up with a jerk?
Describe if anything else is unusual about your sleep: (sleepy, sleeplessness,etc. . if so when)
How much do you cover?
Do you have to uncover any parts?
Circle types of dream that you have
Animal
Cats-dogs
Horse
Wild animals
Snakes
Robbers
Thieves
Anxious
Fearful
Ghosts
Travelling
Riding
Flying
Swimming
drowning
Houses
Fruits
Trees
Water
Snow
Death, Whose?
Dead bodies
Dead person
Parts of Body
Suicide
Being Hungry
Being Thirsty
Drinking
Eating
Fire
Lightning
Storm
Rain
Accidents
Falling
Shooting
Wars
Talking
Singing
Dancing
Pleasant
Business
Money
Day’s work
Forgotten work
Vomiting
Passing stool
Urinating
Blood – bleeding
Excrements / soiling
Romantic
Sexual pleasure
Rape
nakedness
Pain
Illness
Sickness
Mutilations
Praying
Religious
Temple
Church
God
Failure /exams
Unsuccessful efforts for what
Missing train
Being unprepared
Grief
Weeping
Vexation
Quarrels
Jealousy
Insults
Police
Imprisonment
Crime
Murder
Killing
Poison
Misfortunes
Insecurity
Danger
Being pursued
By whom?
-for what ?
If any other, specify
In the space below:
Of people
Children
Parties
Feasts
Marriage
Of events
Remote
Recent
Future
Prophetic
Physical Exertion
Mental Exertion
Fatigue
Coloured
Multi-Coloured
FOR CHILDREN or YOU AS A CHILD
(IN CASE OF ADULTS )
1) Please tick mark once (X) if the child or you as child had any of the following qualities: Tick mark twice (XX) if they are more intense :
Tick Here
Tick here
Obstinacy
Unusual fears
Temper tantrums
Shyness
Disobedience
Unusual attachments (to whom)
Aggression
Habits like :-
Hyperactivity
Biting nails
Destructiveness
Thumb –sucking
Courage
Picking and playing with
Possessiveness
(a) mother’s body parts
Competition-winning spirit
(b)shawls , handkerchieves
Sibling jealousy
(c) anything else
Any special skills
Religious
Unusual desires (for what )
Dullness of memory
Boasting
Slowness (in what)
Stealing
Laziness /Indolence
Telling lies
Sensitive/Emotional
2) Please write in detail, if the mother suffered from any physical or emotional stress during pregnancy .Also describe the dreams the mother got during pregnancy.
3) Please describe any other aspects you feel are striking about the child .
4) Describe one incident from the child’s life when he/she very upset.
HOW TO DESCRIBE YOUR COMPLAINTS
In homoeopathy, prescription is based on precise details of various symptoms from which you suffer. To tell or write to a homoeopathic physician "I have a headache ", " an eruption ", " a cough", would not be enough. If you inform him "I have headache with sharp shooting pains in the left side of the head and temple ", these pains always come on when the slightest cold air strikes the head , the pains wailing about , or when the head becomes cool ". then only you have given all the information required for making a good homoeopathic prescription. The success of the prescription depends, largely on how detailed is your description of the symptoms
We require the following details about your symptoms.
LOCATION : Please give the exact location of sensation , pain or eruption. Also describe where the pain or sensation spreads. Please use the figure on page 23 to indicate location.
SENSATION : Express the type of sensation or the pain that you get in your own words however simple or funny it may seem. You may have a sensation that a mouse is crawling or the heart was grasped by an iron hand or you may have a pain which is cutting, burning jerking , pressing . Express the sensation or pain as it feels to you.
WHAT MAKES YOU WORSE OR BETTER : Many factors are likely to influence your trouble . Some factors may cause the trouble to increase and some factors may relieve the trouble . A detailed list of the factors is given on pages 14 to 16 . Please refer to when describing each of your troubles and indicate which factors make the complaint better or worse.
DISCHARGES : You may have a discharge from ulcers , fistula, eruptions , the skin , lungs, eyes , nose , ears , mouth , private parts, etc. Please describe your discharge under the following aspects .
· The quantity and the time or condition under which the quantity varies i.e. when is it better or worse , increases or decreases ?
· The consistency : Is it thin or thick , stringy or clotted ?
· Is it like jelly, white of an egg, like water , sticky forming a scab etc. ?
· The odour , what does it remind you of ?
· Does it make the parts sore, and in what way?
Please mark in the below figure, the locations of your trouble and write the exact sensation or type of pain you experience at those spots. For example if you have throbbing pain on the right side of you head please mark as shown
clip_image002
clip_image003
IN THE FOLLOWING PAGES PLEASE DESCRIBE EACH OF YOUR COMPLAINTS IN DETAILS IN THE MANNER DESCRIBED ON PAGE 22.
COMPLAINT NO.
WHERE IS THE TROUBLE
WHAT EXACTLY DO YOU FEEL OR HAVE THERE
WHAT ARE THE FACTORS THAT MAKE THIS TROUBLE BETTER OR WORSE
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Labels: case taking format, Clinical, homeopathy
HOMEOPATHIC CASE-TAKING FOR CHILDREN
Notes from Robin Murphy's Pediatric Seminar
April 9 - 10, 1983
I. OBSERVE
A. Eyes: softness, sharpness, fear, hysterical, delicate, evil, irritable, dissatisfied,
pain...
B. Bodies: restless, hyper, slow, timid, aggressive, outgoing, obedient or disobedient,
how sensitive? Shy? Clumsy? Coordinated?
II. Differentiate: Is this a first-aid, acute, or chronic case/problem at this time?
III. Generals: Diet, sleep, weather, mental-emotional state, misc.
IV. Behavioral analysis
A. Playing:
1. Alone or with others?
a) leaders or followers?
b) plays with younger children or peers?
c) imaginative, builders, etc.
2. How does he/she play with animals and toys?
a) obsessed with blanket or toy?
b) rough, break things?
c) fear or love animals?
3. How competitive or aggressive?
4. Reaction to physical pain, scrapes, bumps, etc.
B. Independent vs. dependent
1. How responsible?
2. How handle being alone?
3. Reaction if doesn't get what he/she wants.
4. Reaction to strangers.
C. Patterns
1. Sleep
2. Feeding time, playing time, sleep time.
V. Developmental History
A. Learning to talk, walk, language, comprehension, musculoskeletal development.
B. Toilet training: how child went through it.
C. How was the pregnancy?
D. Family hx: TB, GC, CA
VI. Mental-Emotional State
A. Sensitivity to pain, injury, noise, touch, being carried.
B. Better or worse attention/consolation?
C. Sensitivity to other's pain, to parents fighting, to weather, movies, sad stories, how
sensitive is their imagination?
D. Easily startled?
E. Family dynamics
1. How does he/she get along with siblings? Parents?
2. Reaction to new siblings.
3. Divorce
4. Military family, moved many times?
5. Alcoholism, drugs, tension in family?
6. Motivated by fear? Do parents threaten, frighten, humiliate?
Fear of punishment by God?
7. Is the child compared with a sibling or parent, forced to live up to parent's
role expectations?
VII. Family economics: adequate diet, nutritional status.
VIII. Story about the child. (Usually a chronic constitutional or acute case can be taken directly
from a child aged 6 - 8 or older.)
A. Reactions to griefs, deaths, frights.
B. Mother's description of the pregnancy, labor, and birth.
C. Health and family history.
IX. Objective symptoms
A. Facial expression: observe pupils. How aware is the child of his or her environment?
B. Skin
1. Dry, moist, cool, warm.
2. Healthy or unhealthy?
3. Touch the chest, abdomen, forehead, hands and feet.
Note temp, character, moisture, etc.
C. Sweat: amount, parts that sweat, odor.
D. Moles, warts, birthmarks.
E. Tongue: color, furry or smooth?
F. Breath: Offensive?
G. Reaction to stimuli: light in eyes, noise, jar, pinch.
H. Urine and stool.
I. Strength: check grasp, posture. How does the child hold her head up?
X. Fears: Monsters, ghosts, strangers, the dark, movies, being alone, dogs, death, fears
something will happen to the parents, something is creeping out of every corner,
evil spirits, falling, noises
XI. Sleep: Insomnia: due to pain, fear, over-excitement, want attention, overactive mind?
XII. Food cravings and aversions: including thirst
XIII. Times, modalities for symptoms.
