Govt. of NCT DELHI

Dilli Homeopathic Anusandhan Parishad
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Free Online Treatment Form
Homoeopathy a dynamic, holistic, scientific and philosophical system of constitutional and individualistic drug therapeutics which recognizes all the symptoms of ill health as expressions of disharmony within the person (i.e the patient who needs treatment not the disease,) Homoeopathic Physician defines health as a state of harmonious flow between physical, emotional and mental state. Homoeopathic medicines are made from plants, animal and mineral extracts work by stimulating the body's own healing power. Homoeopathic Medicines are chosen through an interview process.

* Instructions To Be Read Carefully                  * Sample Form

Here is the Homoeopathic physician ready with the team of homoeopathic experts sitting, noting the details as you are describing the details. Homeopathic medicine is mainly selected on the symptoms you give us. If we are to make a successful prescription, we must know all the details of your sickness. We must also understand all the features that belong to you as an individual. This includes your reactions to various factors, your past and family history and your mental make up.
A. Personal Details
Name Age
Sex Address
Pin code
 
State
(if India)
Country
Country
(if other)
 
Telephone number Email
Marital status


Job description:


B.Presenting Complaints: Mention preferably in chronological order or in order of intensity with duration of each complaint .Mode of onset, probable immediate/exciting cause etc. sensation and how better or worse is your trouble.

C.Has the diagnosis been made:  

D.Past History: of any major illness , any aftereffects, any operation, vaccination, suppression, any drugs addicted to etc

E.Family History: Any history of Diabetes, Tuberculosis, Hypertension, Malignancy and genetic disorder

F.Personal and social history:

G.Personal Details:

1.Habits - Do you take drugs, tea, coffee, opium, alcohol, cigarettes etc.? If so how much in quantity often.

2.Response to weather: How you respond to the weather changes summer/winter/spring/autumn/rainy weather.

3.Eating habits. Any cravings, aversion, intolerance

4.Thirst: How much and how often you like to drink water and its relation with weather changes?

5.Sleep. (including position, degree of comfort in sleep and dreams)

6.Sweat.(scanty/copious, does it aggravate or ameliorate ,colour, stain, odour

7.Bowel/Stool habits

8.Urination.

9.Any other detail(optional):

10. Discharges: any discharge from ulcer, fistula, eruptions, skin, lungs ,eyes ,nose, ear, mouth , private parts etc mention the quantity ,time , consistency, odour

H.Describe your nature as perceived by you and others: Mention about your situation in life and about things that bother you. Be total frank and open. Your loves, hates, suicidal tendency, impulsiveness, anxiety, fear, attitude toward family, company, jealousy, obstinacy, depression etc. Any hallucination, illusion, delusion. Memory.

I.Menstrual/Obstetric history: (Duration of cycle, no. of days, kind of flow. Any h/o abortion( self or induced), delivery(normal or cesarean) etc

J.Treatment History:

K.Height L.Weight

M.Built N.Pulse

O. B.P P. Nutrition

Q.Any other finding reported by qualified doctor:

R.Investigation Report:

**Note - “Our replies are advisory and homoeopathic practitioner in the your vicinity should be consulted in case of any difficulty”

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