Govt. of NCT DELHI

Dilli Homeopathic Anusandhan Parishad

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Free Online Treatment Sample Form

Name Age
Sex Address
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State
(if India)
Country
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(if other)
 
Telephone number Email
Marital status


Job description:


B.Presenting Complaints:

C.Has the diagnosis been made:

D.Past History:

E.Family History:

F.Personal and social history:

H.Personal Details:

1.Habits - Do you take drugs, tea,cofee,opium,alcohal, cigrettes 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.

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

5.Sleep.

6.Sweat.

7.Bowel/Stool habits

8.Urination.

9.Any other detail(optional):

I.Describe your nature as perceived by you and others:

j.Menstrual/Obstetric history:

k.Treatment History:

L.Height M.Weight

N.Built O.Pulse

P. B.P P. Nutrition

Q.Any other finding reported by qualified doctor:

R.Investigation Report:

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