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    Case Taking Sheet

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    ssrkm gupta
    This document is a questionnaire for a homeopathic patient intake. It collects information about the patient's personal details, major health complaints, current and past medical treatments, family medical history, lifestyle habits, and previous experience with homeopathy. The questionnaire aims to gather a comprehensive medical history and social context to inform a homeopathic treatment plan.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Case Taking Sheet

    Uploaded by

    ssrkm gupta
    938 views3 pages
    This document is a questionnaire for a homeopathic patient intake. It collects information about the patient's personal details, major health complaints, current and past medical treatments, family medical history, lifestyle habits, and previous experience with homeopathy. The questionnaire aims to gather a comprehensive medical history and social context to inform a homeopathic treatment plan.

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    case taking

    Original Title

    Case taking sheet

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    This document is a questionnaire for a homeopathic patient intake. It collects information about the patient's personal details, major health complaints, current and past medical treatments, family medical history, lifestyle habits, and previous experience with homeopathy. The questionnaire aims to gather a comprehensive medical history and social context to inform a homeopathic treatment plan.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    938 views3 pages

    Case Taking Sheet

    Uploaded by

    ssrkm gupta
    This document is a questionnaire for a homeopathic patient intake. It collects information about the patient's personal details, major health complaints, current and past medical treatments, family medical history, lifestyle habits, and previous experience with homeopathy. The questionnaire aims to gather a comprehensive medical history and social context to inform a homeopathic treatment plan.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 3

    By Homeopathy Learning System

    My Questionnaire

    NAME AGE DATE OF BIRTH

    ADDRESS

    Home PHONE WORK PHONE

    MARITAL STATUS S M D W SEP

    NUMBER of CHILDREN REFERRED BY:

    OCCUPATION EMPLOYER

    MAJOR COMPLAINTS IN ORDER OF IMPORTANCE FOR YOU:


    COMPLAINT SINCE CAUSES

    WHAT MEDICATIONS ARE YOU CURRENTLY TAKING?


    MEDICATION
    SINCE ADVERSE EFFECTS

    WHAT OTHER TREATMENTS OR REGIMES ARE YOU CURRENTLY


    FOLLOWING?

    TREATMENT OR REGIME
    SINCE RESULTS

    WHICH OF THE FOLLOWING HAVE YOU HAD?


    (MARK THE RESPONSE WITH AN ‘X’)

    By Homeopathy Learning System


    By Homeopathy Learning System

    ABSCESSES ALAOHOLISM ALLERGIES AMNESIA ARTHRITIS


    CHICKEN POX COLD SORES DEPRESSION DIABETES EMPHYSEMA
    GOITRE GONORRHOEA GOUT HAY FEVER HEART DISEASE
    INFLUENZA KIDNEY DISEASE LEUKAEMIA MALARIA MEASLES
    MUMPS PARASITES PELVIC IMFLAM PERITONITIS PLEURSY
    RHEUMATIC RUBELLA MATORY DISEASE SCARLET FEVER SEXUAL ABUSE
    FEVER SINUSITIS SUNSTROKE STROKE SYPHILIS
    TUBERCULOSIS HYPNOID VENEREAL WARTS WHOOPING COUGH
    WARTS
    ASTHMA MISSCARRIAGE TONSILLITIS GALL STONES PROSTATITIS
    EPILEPSY PNEUMONIA WORMS HERPES GENI STREP THROAT
    HEPATITIS SKIN DISEASE CANCER MONO YELLOW FEVER

    ANY OTHER MAJOR CONDITIONS:

    ARE THERE ANY OF THE PRECEDING CONDITIONS AFTER WHICH YOU HAVE NOT BEEN TOTALLY
    WELL AGAIN,
    OR
    WHICH HAVE BEEN MORE SEVERE THAN USUAL? WHICH ONES?

    WHAT OPERATIONS HAVE YOU HAD?


    OPERATION WHEN COMPLICATIONS

    WHAT MAJOR INJURIES HAVE YOU HAD?


    INJURY
    WHEN LONG TERM EFFECTS

    AGE OF FIRST MENSES NUMBER OF PREGNANCIES

    WHAT VACCINATIONS HAVE YOU HAD?

    ANY ADVERSE EFFECTS FROM THEM?

    HAVE YOU LOST ANY WEIGHT LATELY? HOW MANY POUNDS?

    WHAT EXERCISE DO YOU DO AND HOW MUCH

    HOW MUCH OF THE FOLLOWING SUBSTANCES ARE YOU USING?

    By Homeopathy Learning System


    By Homeopathy Learning System

    TOBACCO: ALCOHOL:
    COFFEE: “RECREATIONAL” DRUGS:

    INDICATE BELOW, WHICH OF THE FOLLOWING AILMENTS,


    OR ANY OTHER MAJOR AILMENTS, HAVE AFFECTED YOUR RELATIVES:

    ALCOHOLISM ASTHMA DIABETES GOUT INSANITY SKIN DISEASE


    ALLERGIES CANCER EPILEPSY HAY PARALYSIS SYPHILIS
    FEVER
    ARTHRITIS DEPRESSION GONORRHOE HEART DIS PNEUMONIA TUBERCULOSIS
    A
    RELATIVE AGE if AGE AT AILMENTS
    LIVE DEATH
    MOTHER:
    FATHER:
    BROTHERS:
    SISTERS:
    CHILDREN:
    MATERNAL GRANDM:
    MATERNAL GRANDF:
    MATHERNAL AUNTS:
    MATHERNAL UNCLES:
    PATERNAL GRANDM:
    PATERNAL GRANDF:
    PATERNAL AUTHS:
    PATERNAL UNCLES:

    ARE YOU CURRENTLY UNDER THE CARE OF ANOTHER PHYSICIAN(S)?


    PHYSICIAN FOR WHAT CONDITIONS? TREATMENTS

    HAVE YOU BEEN TREATED WITH HOMEOPATHY BEFORE?


    PHYSICIAN FOR WHAT CONDITIONS? WHEN

    By Homeopathy Learning System

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