Adult Patient Case Form

fill the case form online below :

Name

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Mobile Number

Age

Gender

D.O.B

Diet

Marital Status

Occupation (Nature of Work)

Education

Referred to us by

Disease suffered from

Mention one or more diseases you suffered from

Approximate Age

The age when you suffered from any diseases

Duration

The time duration you suffered from any diseases

Whether you completely recovered

Medicines & treatment taken

Which type of treatments and medicine taken when suffering from any diseases

Any other particulars

Family History

Personal History

Did your mother have any problem during pregnancy?

Did she take any drugs during pregnancy? What were they?

Was there any difficulty about your birth? Give Details.

At what age did you start

Teething

Sitting

Standing

Walking

Speaking

Urine control / bed-wetting etc.

Eating indigestibles like chalk, lime, earth, state-pencil, etc.

Any other problem about your growth & development?

Vaccination & Inoculations

Number of time vaccinated for small-pox

Number of time vaccinated for polio

Number of time vaccinated for cholera

Number of time vaccinated for measles

Number of time vaccinated for triple

Number of time vaccinated for B. C. G.

Number of time vaccinated for typhoid

Number of time vaccinated for tetanus

Was there any reaction or particular trouble after any of above vaccination or inocculations?

Give Details

Number of children living and dead

If dead, state causes

Any abortions, miscarriages or still births?

MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES : (AND DETAILED HISTORY OF THE PRESENT ILLNESS, THE ONSET AND COURSE WITH DATES)

ORIGIN OF CAUSE : Can you trace the origin of the present illness to any particular circumstance, accident, illness, incident or mental upset? (e.g. Shock, worry, errors in diet, overexertion, overexposure to cold, heat etc.)?

Appetite and Thirst

How is your appetite?

When are you most hungry?

What happens if you have to remain hungry for long?

How fast do you eat?

How much thirst do you have?

Do you feel any change in your taste and feeling in your mouth?

Bitter food

Salt Extra

Sweet food

Sour food

Bread

Butter

Fats

Milk

Coffee

Mud / Chalk

Spicy food

Cabbage

Onions

Warm food / drink

Cold food / drink

Fruits

Stool

Do you have any problem regarding your stools?

When and how many times a day you pass stools?

Do you have any problem about bowel movements?

Do you have to strain for stool? Even if soft?

Do you have belching or passing gas? Describe its character

Urination & Urine

Any problem about urine?

Any strong smell? Like what?

Do you have any trouble before, during and after passing urine? After passing urine, sometimes 2-3 dropping of urine most of the time but not always?

Any difficulty about the flow? Slow to start, interrupted, feeble, dribbling etc.?

Any involuntarily urination? When?

Sweat / Perspiration - Fever - Chill

How much do you sweat?

Where and on what part do you sweat most?

Do you perspire on the palms or soles?

Is the sweat warm, cold, clammy, sticky, musty, greasy, stiffens the linen etc.?

What is the smell like? E.g. foul, pungent, sour, urinous

Chest - Heat - Cold - Cough

Do you catch cold often? If so, how?

Describe the symptoms, nature of discharge etc.

Is there any trouble with your CHEST or HEART? Is there any trouble with your voice or speech?

Is there any difficulty in breathing?

Do you have cough? Is it more at any particular time?

Sweat/Perspiration– Fever – Chill

What color does it stain the clothing?

Is the stain easy to wash off or difficult?

Any symptoms after sweating?

When do you get fever or chill? What brings it on?

Do you experience any sense of heat or cold in any part of your body at any particular time?

Do you have burning or heat in your palms or soles?

Sexual Sphere (General)

How is your sexual desire?

How do you feel after sexual intercourse?

Any particular feeling or symptoms appear before, during or after sexual intercourse?

Do you suffer from any sexual disturbance?

Any habit like (masturbation etc.) in past as well as present? How often?

Any homosexual inclination?

Did you suffer from any sexually transmitted disease? Syphilis? Gonorrhoea? Herpes? HIV?

What is the method you use for family planning (contraception)?

Any difficulty in erection?

Wanted erection? Unwanted erection? Weak erection? Failing erection? Describe.

Any other trouble in sex? Describe in details.

Sleep

Describe your posture in sleep, on the back, side, abdomen etc.

Are you able to sleep in any position?

In which position you can’t sleep?

Describe if anything else is unusual about your sleep: (Sleepy, Sleeplessness, etc. if so when)

How much do you cover?

Do you have to uncover any parts?

If any other, specify here

Mind

It is now universally acknowledged that your mind has tremendous influence on your body. For giving proper treatment it is absolutely necessary for us to understand your emotional and intellectual nature. We can thus treat you as a whole. In order to understand you we will be asking certain questions. Answer them freely, carefully and completely. This information will help us much in giving you the correct remedy. Also such a remedy will help improve your mental make up. Answer freely. Answer frankly. Answer completely.

Are you anxious? About which matters?

Are you fearful of anything such as animals, people, being alone, darkness, death, disease, robbers, sudden noises, thunder, of the future, of something unknown, high places, etc.?

Are you doubtful or suspicious? Of what?

What are you jealous about? Of whom? From what symptoms do you suffer when jealousy?

In which matter are you impatient? Hurried?

How long do you remember hurts caused to you by others?

How much revengeful are you?

What are you proud of? Does your pride get easily hurt?

Depress, Brooding, etc.?

Do you ever become suicidal? When?

If so in what manner do you contemplate to end your life?

Even then, are you afraid of dying?

When are you cheerful?

Are you sexual-minded?

Any unwanted thoughts any time? What are they?

Have you any imaginary sensations or fears?

Do you hear voices, or that you are called, or anything else in this line keeps on occurring in your mind unduly?

How is your memory?

For what is it poor? E.g. names, places, faces, what you have read, etc.

Do you weep easily? What makes you weep? How do you feel after weeping?

How do you feel if someone offers sympathy and consolation?

Are you easily irritated?

What makes you angry?

What bodily symptoms do you develop when angry? e.g. trembling, sweating etc.

Do you like company? Or like to remain alone?

How seriously are you affected by disorder and uncleanliness in your surrounding?

What are the greatest griefs that you have gone through in your life?

What are the greatest joys that you have had in life?

What activities you deeply like?

Are there any matters which you deeply dislike?

In your opinion, which aspects of your mind and moods are not agreeable to you? In spite of your awareness and maturity, are you unable to change these aspects?

Give a clear cut picture of your situation in life and your relationship with each of your family members, friends and associates in work.

How does the future look to you?

When you are free, what thoughts come to your mind?

Are you worried or unhappy over any personal, domestic, economical, social or any other condition? If so describe in detail

If asked for 3 desires or wishes in life, what will you ask for?

Draw something that comes to your mind at present or your favorite drawing and upload here

Click or drag a file to this area to upload.

Please write in detail, if the mother suffered from any physical or emotional stress during pregnancy. Also describe the dreams the mother got during pregnancy.

Please describe any other aspects you feel are striking about the child.

Describe one incident from the child’s life when he/she very upset.

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