Hi Gavini,
Re: the questionnaires (particularly Snoopy's), my daughter, who is only just beginning formal homeopathic studies, finds them invaluable. They are a great study guide and help to a beginner.

__________________
Two roads diverged in a wood, and I -
I took the one less travelled by,
and that has made all the difference.
(Robert Frost 1874 – 1963)

dear snoopy

did you get any more feedbacks on your questionnaire and did you modify it ?

kindly post the final version for all of us.

regards

dr manish agarwala

Docs,
I liked the questionaire and wanted to fill it up.
Is there a Final Version ?

Thanks

I normally dont ask the specific questions, just i listen to him/her about the complaints, make them to tell their fully story. Finally i ask them to tell me three most important unplasent incidents which has happened in life. I also ask the major incident occured preceeding the current ailment. From that i repertorise the case and get the remedies. very rarely i fail in finding the correct remedy.

__________________
Principles, I can neither live with it nor leave it.

Dear ACHYUTHA4,

Thanks for your reply.Your method of finding of correct remedy with minimum possible questions is quite interesting and valuable.Can you please post a case or two using your shortcut method so that other can adopt the same method to help people.I hope you will not ignore the request.
sajjad.

A homoeopath needs to know some more information besides knowing your name of disease, like location of illness, organ affected, type of sensation, modalities, mental & physical disorders, causations, concomitants strange or rare or peculiar symptoms, personal history of illness, family history with serious or chronic sickness.

This information will help the homeopath to select a proper medicine for you. If you are not sure about the answer of some the questions mentioned below, please leave them blank but do not fill with wrong entries. Underlined entries are most important to answer. You may get help from your Medical Nursing Staff before submitting this proforma. (Homeopath)

----------------------------------------------------------------------------

Personal Information:

-------------------------

Full Name:

(You can use your alias if you want to be anonymous)

Sex:

Age:

Weight:

Height:

Temperature:

Blood Pressure:

Color of Tongue:

Occupation:

Optional Information:

-------------------------

City:

Country:

Phone:

(With city and country codes)

Email Address:

----------------------------------------------------------------------------

Detail Patient History

-----------------

Name of Disease:-

(Diagnosed by Your Medical Doctor

Or if you know the name of your disease)



Patient Description:-

(Important: Write your major complaints

& symptoms briefly in your own words priority wise.)



Cause of your disease / Problem:

(If you don’t know leave it blank)



Period of Disease / Complaints:

(Day, Month or Year when it was started)



Results of major Laboratory Tests:

(Investigations / Pathology Reports)

a.

b.

c.



Comfortable Position:-

(Which activity / position / work

make you better and provide relieve

in your disease or problem?)

Worse state of disease:-

(Which activity / position or work

when perform make you discomfort

and creates uneasiness or pain?)



Change of Weather:-

(Does change in hot and cold

season have any impact on your

disease or symptom?)

Hot & Cold Application:-

(How do you feel in hot or cold

application or when you take bath

or live in warm or cold room)



Good Time:

(At what time you feel trouble-free

or comfortable or painless?

Morning / forenoon / evening / night etc?)

Worse Time:

(At what time you feel uneasiness or discomfort?

Morning / forenoon / evening / night etc?)



Thirst:-

(How is your thirst?)

Appetite:-

(How is your appetite?)



List of medicines used so for:

(Homeopathic and allopathic or Herbal, if any etc)

a.

b.

c.



Habits:

(Explain in detail where necessary)

Are you addict of alcohol?

Are you a smoker?

Are you fond of drinking tea?

Do you like salty/spicy items or sweet stuff?

Are you vegetarian or carnivore?

How is your bowel movement?

(Loose motion or constipation etc)

Are you slim smart or obese etc?

Do you have craving for any food / drink etc?

Do you have any wart or mole on your body?

(First check your body with care)



List of your major past illnesses / diseases:-

(examples: Mumps, chicken pox, whooping

cough, pneumonia, malaria, typhoid etc)

a.

b.

c.



List of major closed family persons diseases:-

(Examples: Asthma, Cancer, Diabetes

High Blood Pressure, Rheumatism or T.B)

a.

b.

c.

Detail of your past Vaccination Chart:-

(If you remember)

a.

b.

Further Explanation:-

(If not covered above)

__________________
Moalij
is your close friend.

some body floated on web, i thought it could be helpful for those who want to be precise in their replies.

__________________
Moalij
is your close friend.

The questionaire is quite good,but alas Kent has died.Now a days people want to be cured in minimum possible time and they are so trained by allopath that soon as they entered the clinic they say they have infection.
sajjad.

I am using this questionary since last 30 years.In some cases I give the questionary to some patients those who can fill up and I double check it if some thing left with out disclosing what they have filled up.
CASE TAKING FORM

Ref.No:

Date:


1. Name of the Patient:

2. Male/Female Age:
3. Address:



4. Present/Past occupation:

5. What is the work you like best:

6. What is the living place like hilly, plain, dry, marshy, malarial or associated with any unhealthy environment:

7. Is your house well ventilated or located in open:

8. Any previous or present history of/habit of drinking, smoking, taking opium, ganja, bhang or narcotics, sleeping pills etc.(Detail of periods and quantity):


9. Any previous or present history of injury(with details)


10.Do you take tea or coffee, if so, how much a day ?

11.Whether thin or fat or plumpy, emaciated or stout ?(details) Height: Weight: Chest: Waist:

12. Any part less developed than others ?






13.Married/Unmarried,If married at what age, if having children how many and at what age, health of the children, is any one dead? if dead, from what disease and in what age ?




14.Present suffering in own language:











15.Duration of Suffering:

16. Give details of present attack as much as you can regarding its onset and course, how long suffering from each attack. Mention aggravation and amelioration of each symptom by day or night, by exposure or exercise, by laying down, sitting up or walking, by wetting or bathing, by perspiration, by constipation or diarrhoea etc.






17.What all treatments did you undergo for your present ailment? Give details whether Allopathic, Homoeopathic, Ayurvedic, Naturopathic etc, with names of medicines used and its result.





18. Exciting cause of the first and subsequent attack (domestic worry, financial loss, fear, anger, over-work, night keeping, loss of semen, loss of blood, working in the Sun, run down health, injury, shock, disappointment, convalescence, fits, from typhoid or other diseases etc.






19. Any eruption on the skin?



20. Any tumor or wart on any part of the body? If the same cured how and when?


21. Any discharge from skin disease? ( Is it thin, thick, watery, bland, excoriating sticky etc. give its colour, quantity & odour if any )


22. Was any operation performed on you? Where, What for and with What result?


23. Did you suffer from typhoid, measles, small-pox, malaria, filaria or any similar disease ? If so, how
many times What was the treatment ?
24. Have you been vaccinated, if so, how many times?

25. Any history of delay in learning to walk, talk and dentition?


26. When you are in company, do you by nature assume leadership or take a position of less importance?


27. Like to sleep in closed doors or prefer to lie with doors and windows open? Like to sleep covering the body always or covering head and body?

28. Are you chilly or warm blooded? Like heat or cold? Like open air?

29. Fond of bathing in cold water or hot water?

30. Exactly at what times of the day or night does the disease or any particular complaint increases and how?


31. Does the disease aggravate/ameliorate by lying on any particular side? Which side is preferred to lie on?




32. Is there any relation of troubles with day or night, summer, winter or rainy season, new moon or full moon or with suppression or cure of any eruption or disease? How was it cured/suppressed? Any external ointment/internal medicines used? Give details.



33. Sleep sound or disturbed, refreshing or not? Sleepless from what time to what time? Any aggravation or amelioration during or after sleep?



34. Any dream of cat, snake, robbers, fire, dead people, daily work, floating in water, air etc.


35. Do you put your hands above your head while sleeping or feet and hands out of bed?



36. Feels chilly and feverish before or during the attacks? And become restless then?




37. Cares for dry warm application and massage over the limbs.


38. Thirsty and ask for small quantities of water at short intervals or large quantity at a time, how many glasses you take in 24 hours?


39. Wants to lie in dark/lighted room:


40.Does the attack occur at fixed intervals or does it alternate with neuralgia or any other complaint?

41. Usual Diet:





a) Taste in mouthBitter, sweet, metallic, sour, salty, burning etc.)


b) Desire of food/drinks(dislike/aversion/aggravation or amelioration by taking foods/drinks, if any, give details:



42. Head: Heat or burning or vertex, perspiration on front or back, itching of scalp, dandruff, falling of hair, premature grayness etc.




43. Mouth: Bad odour, salivation, taste, gums swollen, painful etc. Teeth carious, coated with tartar, pyorrhea, grinding of teeth at night etc.


44. Throat: Any pain, right/left, pharyngitis, tonsillitis, chronic enlargement of tonsils with frequent attacks of inflammation. Tonsils removed by operation or not? Uvula elongated? Cracks, fissures on lips if any, tongue coating or mark on tongue (thin or flabby, moist or dry, any ulcer, if so, its nature etc.)




45. Eyes: Lachrymation with itching or any peculiarity be noted in details:



46. Nose: Stoppage of nose, which nostril? Watering of nose, Itching of nostrils and on nose, other peculiarities if any, loss of smell etc.


47. Ear: Any discharge, thin or black, colour and odour and any other peculiarities if any, deafness, loss of hearing etc.



48. Lungs: Cough dry or moist, stringy and other peculiarities if any?



49. Heart: Any palpitation, aggravation from motion, riding or going upstairs or coming down in ladders, amelioration from or any other peculiarities etc.



50. Chest: Mention any suffering from any disease of chest.



51. Abdomen: Any distention of abdomen, any eruction, does passing of flatus relieve the patient?


52. Stomach: Appetite increased or decreased etc.



53. Sweat: In which part is most marked. Is the attack worse or better with perspiration, any peculiarities regarding sweat, give details.


54.Urine; any bad odour, sediment, of what colour and consistency? How many times in 24 hours, whether able to control or it passes automatically, more in day/night/eve etc. Other particulars if any?


55. Stool: Colour, odour, foul or not ? Any ineffectual urging to stool? Is the bowels constipated or loose? How many times in 24 hours?



56. Hands & feet: If burning, sweat, numbness etc. describe.



57. Anus: Is there any pain or discharge? Any fissure or eruption, any history of piles and whether of bleeding nature? How was it cured? Any external ointment Used? If so, give details.






58.MENTAL SYMPTOMS:

a. Mild or angry and irritable temper, quarrelsome, fault finding and obstinate, suspicious of others, jealous etc.


b. Is very talkative or silent absent minded, cheerful gloomy or timid?

c. Neat and clean or of dirty habits?

d. Desire to be in company or keeps aloof /

e. Any fear of death or suicidal tendency. Disgusted with life from frequent attacks, from pain or from imaginary causes?


f. Memory weak or active, gradual loss of memory etc.


g. Weeping mood and involuntary sighing, cries when reprimanded or gets more angry.

h. Cries for sympathy?

i. Keeps busy, wants to do everything in a hurry or slowly or in a normal manner, very active or dull and backward mentally:


j. Want of concentration, inferiority complex etc.


k. Any other mental symptoms, whether rare and peculiar or otherwise.


59. FOR WOMEN ONLY

a. Details of menses: In which age started ?



b. Whether any break from starting, if so , how regularized give details:


c. Is there any change of duration of M.C, if so, when and how give details:


d. Duration of the M.C :–early or late, regular/irregular etc.

e. Flow continues for the period of.


f. Colour of the flow and quantity, clotted/thin/thick, odour, if any, give details.



g. Pain if any, before/ after/at the period/ where, when and how? How ameliorated/aggravated etc.



h. How does menses effect the patients troubles in general?


i. Is there any history of leucorrhoea, give details, thin/thick, colour, odour, period, reaction in the skin, change of colour when dry etc.



j. Desire of coition more/less/normal/absent, give details of any other particulars if any.



k. Condition of breasts at the time of M.C – tender/painful/hard, sensitive, swelling etc, before/after/at the period. Breasts atrophy, cracks, numb or any other particulars or peculiarities be mentioned.


l. Give details about deliveries, abortions, MTPs if any .


m. If you are having children are they healthy?



n. In what age your mother and her sisters and your sisters attended menopause?



60. FOE MEN ONLY

a. Details of sexual abuses if any.


b. Any history of ejaculation in dreams/night/day/urination/at stool-before/after. If so, what is the number in a week or in a month?



c. Has the penis any abnormality? Give details.



d. Details of sexual desire- strong/weak/absent/normal or with any other peculiarities give details.


e. Does the patient always thinks about sexual matters?



f. Mental and physical condition after and before coition, if any peculiarities, give details.




g. Any other history about the genitals or sexual matters with peculiarities if any give details.


h. Mental and physical condition after and before coition, if any peculiarities, give details.



i. Any other history about the genitals or sexual matters with peculiarities if any give details.



61. FAMILY HISTORY

a. Parents alive or dead - if alive, the condition of their health. If dead- at what age and from what disease?








b. Were they suffering from any particular disease?




c. Brothers and sisters- how many are they ? Are all of them live? If dead, from what disease and at what age? Condition of their general health etc.( give details.)






d. Health of paternal and maternal uncles and aunts, grand fathers and grand mothers, if dead, at what age and from what disease?








62.HOBBY: In general:
Casual:

Of Importance:


63.OTHER REMARKABLE SYMPTOMS: if any,(Including pathological findings)

__________________
Dr.S.K.Pattnaik,HMD,M.D(Alt.Med),Ph.D
Chairman,Indian Council for Holistic Health Care
http://holihealcouncil.forumup.in/
http://artofhealing.freeforums.org/
http://ichhc.tripod.com/

Can this questionnaire help someone with very serious psychological problems?

Do only 200 and 1M potency work for very serious psychological problems?