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HISTORY FORMS

Medical history Forms for Homeopathic Treatment

  • MEDICAL HISTORY FOR HOMEOPATHIC TREATMENT

  • Direction for written submission

  • INTRODUCTION

  • For finding a correct homeopathic medicine, lot of information with regard to the (1) complaints—(a) main as well as (b) subsidiary—and                          (2) person as an individual is required. We need to study patient in his present & past environment, in all areas viz. family, society & work.

  • Incomplete information will make correct choice difficult. You are requested to supply all information without keeping back anything irrelevant or of little importance. The information you supply is basis for further enquiry designed to assist you in the delineation of the problem. Full co-operation there for, is requested. All information supplies are of course strictly confidential

  • Preliminary  Information

  • Name                                                               Date of birth                   Sex:

  •  Diet:                                                   Addictions                              Education

  • Job /jobs                                                         Current family set up:

  • CHIEF COMPLAINTS

  • Full description of the trouble right from the time of onset. Its subsequent development and spread and response to treatment taken.

  • OTHER COMPLAINTS

  • PERSONAL DATA

  •     [1] Job satisfaction: full description of responsibilities at works any strain and Job satisfaction

  • [2] Emotional nature and intellectual attainments and aspirations. Indicate to what extent you have been able to realise them. Give clear-cut picture of your relationship with family members, friends and associations. Give full Idea of your responsibilities in life and what you feel about them

  • [3] Reactions to surroundings

  • Food: desires & aversions, foods that do not suit, etc.

  • General environment: weather, temperature, bath recreations, addictions, etc. what type of weather you like most & what type of weather does not suits you.

  • Sleep and dreams.

  • Sex (inclusive of. menstrual and obstetric history).

  • PREVIOUS ILLNESS

  • Give a resume of the various illnesses you have had and to what extent these any bearing on present troubles.

  •                                         FAMILY HISTORY

  • Data concerning the parents, Brothers, and Sisters. State details concerning the health of wife and children.

Medical history forms for homeopathic treatment of children

MEDICAL HISTORY FOR HOMOEOPATHIC TREATMENT OF CHILDREN

Directions for a Written Submission

 

INTRODUCTION:

 

For finding a correct Homoeopathic remedy for your child, a lot of information with regard to the (1) complaints (a) main or chief as well as (b) subsidiary and (2) the person of the patient is required.

Incomplete information will make correct choice difficult. You are therefore requested to supply all information without keeping back anything as irrelevant or of little importance. The information you supply in the note forms the basis of further enquiry. Full co-operation therefore is requested. All information supplied is, of course, strictly confidential.

 

PRELIMINARY INFORMATION

  • Please supply the following information about your child as a standard routine.

                        Name, address & date of birth. Standard Dietary habits- veg./ non veg./ eggs. Habits- tea/

                        Coffee/ milk/ chocolate/ ice- cream, etc.

  • Description of the current family set up. Full description pertaining to all the members, their age, relation with your child.

  • Please supply the information about daily routine from getting up in the morning to retiring at night.

  •  

CHIEF COMPLAINTS: & other complaints

 

Describe what bothers the child most. Each trouble should be detailed as under:

Full description of the trouble right from the time of onset. Its subsequent development and spread and response to treatment taken. This should give a full idea of:

  1. Area affected: Location, extension, direction of spread: the march of events.

  2. Sensation(s) experienced in the area of trouble.

  3. Conditions that have brought on the trouble; examine the circumstance that obtained just before or at the time of onset, paying attention to physical as well as emotional factors.

  4. Conditions that increase the trouble or those that affords relief.

  5. Other troubles experienced at the same time along with main trouble, e.g. - change in appetite & thirst, perspiration, nausea, vomiting, gas, sleep disturbances etc. with pains.

 

PERSONAL DATA:

Give a full account of the following:

  1.  Physical description of the Child.

  2. (a) Emotional nature: Right from beginning, describe child’s nature like Anger, Fear, Attachments, Shyness etc. mention if you have noticed any change in the child’s behavior / Nature recently.

  1. Intellectual: School Performance, Extracurricular activities, hobbies, etc.

  2. Give a clear cut picture of child’s relationship with the family members, friend & teachers (School & tuition). Discuss the difficulties experienced by the child in any of these & effects on the child.

  1. Reactions to surroundings.

    1. Food: Desires & Aversions, including foods that do not suit etc.

    2. General environment: weather, temperature, bath, cloths, covering- in respect to all weather.

    3. Sleep & dreams.

  2. Growth & development of child.

    1. Type of delivery & birth weight. Any problems during delivery & soon after birth.

    2. Mother’s health & emotional state during pregnancy & after delivery. Breast feeding difficulties, if any.

    3. Milestones: State the age at which the child started teething, sitting, walking, talking, etc. any complaints at that time. Give details of toilet training.

 

PREVIOUS ILLNESS DETAILS IF ANY

FAMILY HISTORY: Data concerning the parents, brothers & sisters. Also state details concerning the health of grandparents & other blood relatives on both sides.

GENERAL COMMENTS:

Include here any items which have not been included above

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