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Online Homeopathy Consultancy : Patient History

Quick Inquiry Patient Details - Full Inquiry Form
   
Name* :
Age* :
Sex :
Marital Status :
Occupation :
Address :
City* :
Country* :
Phone :
Email* :
Chief Complains
Chief Complaints :
If the case is already diagnosed then diagnosis of the case :
If investigations done, reports of investigations :
Under any medication, if yes specify :
Present History
Whether patient is suffering from any diseases like Arthritis, Blood Pressure, Diabetes, HIV, Tuberculosis Or cancer specify since when :
Past History
Any diseases which occurred in the past Tuberculosis, Hepatitis, Typhoid etc. any others specify when :
If Patient has undergone any surgical intervention for what and when :
Family History
Family history of any diseases (for Father, Mother, Brother, Sister) Blood pressure, Diabetes Mellitus, Hepatitis, Tuberculosis, Cancer, HIV Infection etc. any others specify Arthritis :
If married – about children. Any diseases specify :
Patient Nature
Appetite :
Thirst :
Craving for any food items specify :
Aversion for any food items :
Perspiration :
Any parts specify :
Offensive smell :
Urine :
Pain :
If yes type of pain specify :
Motion :
No. of times /days :
Thermal : :  
Climate – which patient prefers :
Takes bath in :
Addictions :
Tobaco if yes quantity
Alcohol if yes quantity
Drug Specify
For Females: Menstrual history
First Menstrual Period :
Last Menstrual Period :
Attained Menopause :
Aversion for any food items :
Perspiration :
Complaint associated with Menses :
Before
During
After
Leucorrhoea :
Sexual History
About sexual life. Any problems specify :
About fertility. if any problems :
Mental Features of the patient
Patients reaction towards the society. Whether irritable, anxious, tension, attachments, likes company of friends, brooding, any suicidal thoughts.
Any other symptoms Specify :
We need an elaborate case history for selection of remedy. Please co-operate with us and fill necessary columns.
   
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