Homeopathic Case-Taking
Name:
Date of birth: ______________ Gender: _______B/P: ____ Weight: ____ Height: ______
Marital Status: _______ Age at merited____ Do you have any children? ____ How many? _____________Year deference the 1st baby come____________
Family medical history:
Past history of health:
Have you been hospitalized? ______ Date: ___________ Where? ________
Have you taken medications in the past? If so, which medications have you taken?
What was your response to the medication?
Have you been vaccinated? If so, what vaccines have you received?
Do you have any allergies? ____
List the number of dental fillings ____ type of fillings ______ and other procedures __________ you have had.
General Symptoms:
Are you presently taking medications? If so, which medications are you taking?
Chief complaint?
When did it first occur?
What’s your symptom?
Describe the sensation experienced.
Give the precise location.
List any concomitant symptoms.
Modalities:
When do your symptoms get worse?
morning __ evening __ night __ during sleep __ on rising __ before a thunderstorm __ after a thunderstorm __ in damp weather __ in cold weather __ wearing tight clothes __ in a warm room __ while washing oneself __ in bed __ while moving around __ during rest __ in a closed room __ in crowded places __ in the winter __ in the summer __ in the spring __ in the autumn __ at the sea __ in the sunlight __ lying on ones back __ lying on affected side __ while exercising __ while talking __ when the temperature changes __ at the smell of tobacco __ on missing a meal __ on the onset of a menstruation __ in cold, wet weather __ in bed __
When do your symptoms get better?
bend backwards __ doubled over __ upon moving __ resting __with cold applications __ warm applications __ in the morning __ in the evening __ in the night __ listening to music __ applying pressure __ uncovering the feet in bed __ during the summer__ at the sea __ outdoors __ opening a window __ left alone __ while eating __ on the onset of a menstruation __
How’s your appetite?
Good __ decreased __ never hungry__ always hungry __ capricious eater__ can’t finish a meal __ hungry soon after a meal __ List any eating disorder ____________
What do you have an aversion to?
Food ___ water___ meat ___ bread__ fish__ shellfish __ butter__ eggs ___ fruits__ milk__ onions __ pickles ___ wine ___vegetables ___ cabbage __ beans __ pork __ potato ___ soup __ ice cream __ cold food __ warm food __ sour food __ sweets __
What or who do you dislike?
a family member __ husband __ wife __ strangers __ company __ friends __ music ___ noise __ sun__ light __ odours __ exercise __ being indoor __ closed windows __ tight clothes __ being contradicted __ being consoled __ mental work __ writing __ being wrong __ bathing __
What do you have a strong desire for?
alcohol __ coffee __ milk __ bread __ butter__ cheese__ meat __ eggs __ chocolate __ lemon__ pickles __ potato __ sweet foods __ ice cream __ cheese __ pastry __ salty food __ fatty food __ sour food __ bitter food __ fish __ oysters __ beer__ wine __ tea __ pop __ fruits __ vegetables __ hot foods __ spicy foods __ cold foods __ room temperature foods __
What do you thirst for?
large quantities of water __ small quantities of water __ hot drinks __ cold drinks __ room temperature drinks __ ice cold water __ coffee __
What do you have an addiction to?
Alcohol __ cigarettes/tobacco __ sex __ coffee __ chocolate __ narcotics __ illegal drugs __ sedatives __ diet pills __
Emotional Symptoms:
mania __ emotional instability __ hallucination __ confusion __ depression __ poor memory __ poor concentration __ learning disability __ suicidal tendencies __ anger __ broken heart __ anxious ___ repulsion for sex __ desire for attention ___ aversion to mental work __ aversion to company __ aversion to children __
What do you fear most?
enclosed spaces___ failure __ affection __ contradiction ___ others opinion ___ being touched __ heights __ crowds __ snakes ___ the dark __ driving __ death __ illness __ burglars __ thunderstorms __ being alone __
How would you describe your sleep?
normal __ deep __ disturbed __ restless __ interrupted __ short __ night terrors __ sleep walk __ sleep apnoea ___ insomnia __ bad mood on rising ___ avoid sleeping on the right side of the bed __ avoid sleeping on the left side of the bed __
Do you have a recurring dream? ___ Describe your dream: __________________
Sexual symptoms:
Excessive sexual appetite __ premature ejaculation __ pain during sexual activity __ problems with orgasm __ impotence __ infertility __ vaginal dryness __ sexual dysfunction __ difficult coition __ repulsion for sex __ sexually dissatisfied __ painful erections __
Physical Symptoms:
What’s your body shape?
normal __ slender __ chubby __ overweight __ underweight __ tall stature __ short stature __ medium stature __ thin arms __ flabby upper arms __ thin legs __ flabby thighs __ broad shoulders __ wide hips __ narrow shoulders __ narrow hips___ flat abdomen __ big butt __ hourglass shaped body __ pear shaped body ___
What’s your face shape?
oval __ square __ round __ heart shape __ diamond shape __ high forehead __ receding chin __ square jaw __ big cheeks __
What’s the colour of your skin?
White __ pink __ olive __ brown __
What’s your facial expression?
Happy __ sad __ fierce__ cold __ tired __ angry __ suspicious __ smiling __ proud __ frightened ___
What condition is your skin?
healthy looking __ unhealthy looking __ dry __ oily __ combination __ acne __ flushed__ shallow__ liver spots __ freckled __ porcelain skin __ goose flesh skin __ rashes __ discoloration __ excessive sweating __ dirty looking __ moles __ itchy__ bruises __ warts __ hives __ cysts __ boils __ skin infections __
What is your natural hair colour?
Blond __ red __ black __ brown __ grey __salt and pepper __
Describe your scalp condition:
Dry __ oily __ bald patches __ dandruff __ hair loss __
What colour are your eyes?
Blue __ green __ hazel __ brown __ dark brown __
Eye symptoms:
dry __ itchy __ burning __ discharges __ pain __ watery __ sunken __ contracted pupils __ strabismus __ blurred vision __ diplopia __ myopia __ tunnel vision __ photophobia __ swollen lids __ long eye lashes __ dark circles under the eyes __ tears __ sties __ sensitive __ redness __
Ear symptoms:
Impaired hearing __ eruption behind ear __ itching in __ noises in __ fluids in __ inflammation in __ discharge from ears __ recurring ear infection __ pain left __ pain right __ pain behind __ ulceration in front of ear __ ringing in the ears __ hearing loss __
Nose symptoms:
long __ crocked __ cold tip __ red tip __ brown saddle on the bridge __ dry nostrils __ discharge right nostril __ discharge left nostril __ epitasis __ stuffed nose __ dry catarrh __ congestion of blood __ obstruction of the airways__ polyps __ sensitive to odours __ ulcers __ difficulty breathing __ loss of smell __ sinus infection __ post-nasal drip __
Mouth symptoms:
Dry mouth __ drooling __ bad breath __ oral thrash __ canker sore __ excessive salivation __ discoloration of the tongue __ protruding tongue __ ulcer __ bitter taste __ speech difficulty __
Lips symptoms:
Dry __ cracked __ chapped __ swollen __ herpes __
Teeth symptoms:
asymmetric __ long __ short __ rectangular __ loose __ sensitive __ grinding __ numerous caries __ missing teeth __ bleeding gum __ gum abscess __ pain chewing __ pain drinking something cold __ black teeth __ green teeth __ yellow teeth __
Internal throat symptoms:
dry __ inflamed __ sore __ sensation of a lump __ excessive mucus __ narrow sensation __ choking sensation __ swallowing difficulty __ pain swallowing __ hoarseness __ loss of voice __ throat infection __
External throat symptoms:
Indurations of glands __ lump in the throat __ goitre __ pain of the thyroid gland __
Respiratory symptoms:
wheezing __ accelerated breathing __ difficulty breathing __ deep breathing __ asthmatic __ shortness of breath __ obstructed respiration __ weak respiration __ gasping for air __ irregular respiration __ slow respiration __ loud __ rattling __ whistling __ asphyxia __ frequent respiratory infections __ bloody sputum __ yellow catarrh __ persistent cough __
Digestive symptoms: cramps __ bloated __ heartburn __ feeling of emptiness __ fullness __ heaviness __ indigestion after a meal __ cutting pain __ gnawing pain __ rumbling __ colic __ flatulence __ stomach ulcer __ hiatus hernia __ anorexia __ bulimia __
Cardiovascular symptoms:
Heart palpitations __ fluttering sensation __ constriction of the heart __ dilation of the heart __ chest pain __
Stools
regular __ frequent __ hard __ large __ scanty __ soft __ dry __ watery __ bloody stools __ loose __ copious __ greasy __ frothy __ bilious __ fetid __ odourless __ colic before a stool __ an urge without success __ slimy mucous in stool __ involuntary stool __ painful stool __ diarrhoea __ constipation _
Shape of stool
Shape __ flat __ narrow __ chopped __ pasty __ balls like sheep dung __
Colour of stool
brown __ green __ grey __ black __ yellow __ white __ ash __ bluish __ orange __
Bladder symptoms:
Weak __ painful __ obstructed __ calculi __ infection __ retention of urine __ sensation of fullness __ paralysis
Urological symptoms:
frequent urination __ albuminous __ acrid __ alkaline __ bloody __ burning __ increased __ scanty __ involuntary __ urging __ dribbling __ interrupted __ retarded __ bloody urine __ painful urination __ urine comes out in drops __ cloudy __ greyish __ saffron colour __ watery __ prostate problems Arthritic Pain:
Where do you feel the pain?
Hand _ finger _ wrist _ shoulder _ thumb _ hip _ leg _ calf _ ankle _ foot _ toes _
Where do you feel stiff?
Shoulder __ hand __ finger ___ hip __ knee __ ankle __
Where do you get swollen?
Hand __ wrist __ fingers __ knees __ legs __ ankles __ toes __
Eczema & Psoriasis:
Where do you have eczema?
Face __ behind the ear __ inside the ear __ neck __ finger __ hand __ arm __ leg __ foot __ genitals __ anus __
Where do you have psoriasis?
In the elbow crease __ in the knee crease __ behind the elbow __ on the knee __
Where do you have dry itchy skin?
Hands ___ feet ___ knees __ elbows __ scalp __ face __
Describe your menses:
Early __ late __ normal __ irregular __ scant __ heavy __ painful __ long duration __ short duration __ dysmenorrhoea __ metorrhagia __ blood clots __ get headaches during menstruation __
What’s your disposition?
sweet __ affectionate ___ shy___ meticulous __ indifferent __ impulsive __ loquacious ___ jealous ___ happy __ messy __ cheerful ___ capricious ___ absent-minded ___ quarrelsome ___ anxious __ destructive __ easily offended ___ generous __ people pleaser ___ a bully ___ argumentative ___ the life of the party __ quick to do things __ vain ___ slow learner ___ violent __ ambitious ___ obsessed with religion ___ verbally abusive ___ compulsive ___ an outdoor person ___ angry when consoled __ afraid of the dentist __ impatient ___ philosophical __ afraid to die __ leader ___ paradoxical __ lover of animals __ singer __ moved to tears from music __ rude __ relieved by crying __ hyper __ sad __ silly __ discouraged __ dissatisfied __ serious __ domineering __ fastidious ___ dictatorial __ passive __ thirst less __ sensitive to noise __ worse in the heat __ worse in dry weather __
