Case Record Form




PLEASE READ THIS FIRST BEFORE FILLING THIS FORM

You have to get well. We are here to select the best possible medicine for you .In order to do that, we depend on your co-operation.

HOMOEOPATHIC 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.

This information enables us to select the remedy that removes your sickness.The medicine also makes you well as a whole person.

In order to find out all about you, we shall be asking you many questions. Each one of these questions has a definite meaning and significance for us. There is not a single question that is useless. Even something that you may think is not connected with your trouble, may be the most important factor in deciding the correct homoeopathic medicine. That is why you must be free and frank and give us the fullest possible information on each point. Please read each question carefully, think and if necessary, consult someone close to you and then answer completely. Do not keep anything back. Remember, whatever you tell us shall remain absolutely confidential.

THIS QUESTIONNAIRE FORM HAS 8 PARTS :

• About your past illnesses and family illnesses. Please take time to answer this part with the help of your family members before coming to us.

• History of your present illness.

• About all the parts of your body.

• Deals with the factors that affect your health. Please think carefully about each of the factors mentioned and write what specific effects they have on you.

• About your mental state and your emotional nature. Please write in this part about your situation in life and about all the things that are bothering you. Be totally frank and open

• About your sleep and dreams.

• For children or you as a child.

• In this part you are given instructions on how to report each of your complaints.Read the instructions first. Then make a list of your complaints and describe each of them according to the instructions.

Download Case Record Form

Click on above link to download the case record form. You can then print it, fill it up and mail it to us