History Form

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Introduction

• 1. For finding out a correct Homoeopathic Remedy, lot of information with regard to the
  • i. Complaints -
    • (a) Main as well as
    • (b) Subsidiary-and
  • ii. The Person of the Patient is required
  
  
• 2. 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 designed to assist you in the further delineation of the problem. Full co-operation, therefore, is requested. All information supplied is, of course, strictly confidential.


• 3. Since the enquiry can be a time consuming process and a lot of information is being collected we require to record it systematically and, at times, we may find it necessary to administer to you further tests in which you are called upon to write out further. To facilitate this, we have evolved a special procedure in which the preliminary study is carried out by a physician specially assigned to this job and when your Case Record is ready, we examine it to find out if it is sufficient for instituting treatment or it requires further detailed processing of information and study of your Case. If so, we give you a further suitable appointment for finalizing the line of treatment.


• 4. We are sure you shall be fully co-operating with us in rendering you the best possible service.

Preliminary Information:

• Please supply the following information as standard routine:
  • Name in full
  • Address
  • Date of Birth
  • Sex
  • Status, Single\Married or Widow-ed since\Divorcee since
  • Religion\Community\Sect
  • Vegetarian\non-vegetarian\Eggs
  • Addictions: Tobacco, Chewing\Smoking, Tea, Coffee, Beer, Whiskey and Liquors (please state the quantity consumed daily)

Educational career and qualifications:

Occupation, current and previous with full description of responsibilities and job satisfaction, Address and Telephone No.

Description of the current family set-up:

Full details pertaining to all the members, their ages, location, work they are doing and your relationship with responsibilities for them, include in your those who have died, stating the age of death, the year and the cause of the same.

Your daily routine from getting up in the morning at night in this your schedule furnishing full details in respect of the quantities consumed. Financial responsibilities and strains (present as well as past). Difficulties experienced, place of work\family set-up\Social, give a full account.

Chief Complaints:

Describe fully what bothers you most. Each trouble should be detailed as under:

• 1. Full description of the trouble right from the time of onset. Its subsequent development and spread and response to treatments taken. This should give full idea of:
  • i. Area affected: Location, extension, direction of spread, the march of events
  • ii. Sensation experienced in the area of trouble
  • iii. Conditions that have brought on the trouble: examine the circumstances that obtained before or at the time of onset paying attention to physical as well as emotional factors
  • iv. Conditions that increase the trouble or those that affords relief
  • v. Other troubles experienced at the same time along with the main trouble for example....perspiration \nausea \vomiting \gas\with pains

Other Complaints:

Describe here all other troubles you might be having or have in the past experienced. Each should be described fully as suggested above for the Chief Complaint.

Personal Data:

Give full account of self.

• i. Physical description of self
• ii. Emotional nature and intellectual attainments and aspirations, indicate to what extent you have been able to realize them. Give a clear-cut picture of your relationships with the family members, friends and associations. Give a full idea of your responsibilities in life and what you feel about them
• iii. Reactions to surroundings:
  • Food: desire and aversions, foods that do not suit, etc.
  • General environment: weather, temperature, bath, recreations, addictions etc.
  • 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 have any bearing on present troubles.

Family History:

Data concerning

• Parents
• Brothers and Sisters
• State details concerning the health of wife and children

General Comments:

Include here any items which have not been included above.

Enclosures:

• a. Medical Report and opinion on your state of health from your physician.
• b. Copies of Reports of investigations done.
• c. X-ray plates, Electrocardiograms, etc.



Presentation:

Your history is to be filed in the standardized Case Record which we employ. To facilitate that, you are requested to write in the following way.

• a. Take papers of the size 7" (width) X 13" (length)
• b. Write in the way the history is printed
• c. Leave margin of 1" at the top in front, and at the bottom on the back