New Homeopathy Patient Intake Form

Dear JH,

HAPPY NEW YEAR!

Well, I use this form that may require usual enhancement or you may take some additional items from this and implement in your form.

Please keep up the good work. You efforts are greatly appreciated!

1. ID
2. Age
3. Sex
4. Single/Married
5. weight
6. Height ….
7. country
8. climate
9. List of your complaints

10. Since how long are you suffering from each complaint

11. Diabetic or non-Diabetic
12. Desire sweets/sour/salt
13. Thirst
14. Tongue and Taste
15. Current BP (without medicine and with medicine)

16. What exactly is happening?

17. How do you feel?
18. How does this affect you?

19. How does it feel like?
20. What comes to your mind?
21. One situation that had a
big effect on you?

22. How did that feel like?
23. What sensation do you experience in that situation?

24. What are you showing by that gesture of your hand (Habits or Actions)?
25. Current medicines you are taking?

26. Family Background
27. Educational Qualifications of the patient

28. Nature of work, what do you do for living?

29. Desires, likes and dislikes for food

30. Name of foods which increase your problem

31. Mind-behavior, anger, irritability, hurry, impatient…and so on.. How are you different from other persons, public speaking or not , you can describe all of the details about your behavior, love and affections.

32. Aggravation (increases-time, season,)& Amelioration (Decreases)

33. Attached here your photographs of the affected area. (if required/optional)

34. Location of the disease
35. Side of the problem (Right or Left), (Upper or Lower part of body)

36. Color of the secretions/discharges e.g urine, stool, sputum, Saliva etc.

May God Bless You?

Regards
Nawaz

please, to where i should send the form after i filled it out?

to the list?

thank you.

leila.

Hi Sir,

My name is deepa
Sub-Regardding hard movable lump

Gender -Female
Age -25 yrs
Height - 5'7inches
Weight -46 kgs.

General Appearance- I am tall and small built and my complexion is fair.I have never suffered from any chronic disease and i have no allergies.Sometimes i get skin rashes that go away with season change.

I have used calc fluor 30 for the lump for 3 months but no change was seen in the lump.


Please answer the following questions in a descriptive manner after careful analysis and recollection of previous experiences and happenings.

1. Describe your main suffering?
A.I do not experience any sufferings due to this lump it decreases a little bit during my period cycle.

2. What other physical sufferings do you have in your body?
A.None
3. What mental sufferings / feelings do you have associated with your physical sufferings?
A.I often fear that this lump can become cancerous in future

4. What exactly do you feel when you are at your worst? Describe the sensation in your own words.
A.I want to be alone at this situation.

5. When did it all start? Can you connect it to any past event or disease?
A.No particular event or disease i just noticed it once when i was sleeping and my hands felt a hard lump on my chest.
6. Which time of the day you are worst?
A.Never.

7. What are the things which aggravate your suffering and which are those which ameliorate the same? Example- time, temperature, pressure, rubbing, washing, eating, tight clothing etc.
A.These conditions never bring any change on me.
8. Do your think your sufferings have relation to any external stimuli (like, change of place) or any internal biological changes in the body, like, menses (in females)?
A.NO.
9. When do you feel better, during hot weather or cold weather, humid or dry weather?
A.I prefer dry and hot weather.
10. Describe your general mental set up? Are you Moody, Arrogant, Mild, Agreeable Changeable, Nervous, Suspicious, Easily offended, Quiet, Arguing, Irritating, Lazy etc.

A.I am impulsive and agreeable and sometimes moody.


- How do you feel before or during a thunderstorm?

A-Nothing i remain as usual

- Are you sensitive to external stimuli like smell, noise, light etc?

A-I dislike loud noises

- Do you have any typical habit or gesture like nail biting, causeless
Weeping, talking to one self etc?
Ans- No

- How do you feel about your friends, family, your children and especially your husband / wife?
Ans- I trust them like anything and love reciprocating for them.

11. What are your fears and do you dream of any situation repeatedly?

Ans- No Dreams but i fear of losing my loved ones.

12. What do you crave for in food items and what are your aversions?
Ans- Nothing in particular.I like taking excess of salt and sweets.

13.

Homeopathy and Health Forum
New Homeopathy Patient Intake Form
From Homeopathy International 1 on 2010-12-30
4 replies 94 views
I am adding this again as a new discussion. If someone has created a newer homeopathy patient intake form with more information, please add it to the forum.


Gender:
Age:
Body Type:
Height:
Weight:
General appearance:
Have you used homeopathic medicines before? If so what, and what homeopathic potencies did you use?

+

Please answer the following questions in a descriptive manner after careful analysis and recollection of previous experiences and happenings.

1. Describe your main suffering?

2. What other physical sufferings do you have in your body?

3. What mental sufferings / feelings do you have associated with your physical sufferings?

4. What exactly do you feel when you are at your worst? Describe the sensation in your own words.

5. When did it all start? Can you connect it to any past event or disease?

6. Which time of the day you are worst?

7. What are the things which aggravate your suffering and which are those which ameliorate the same? Example- time, temperature, pressure, rubbing, washing, eating, tight clothing etc.


8. Do your think your sufferings have relation to any external stimuli (like, change of place) or any internal biological changes in the body, like, menses (in females)?

9. When do you feel better, during hot weather or cold weather, humid or dry weather?

10. Describe your general mental set up? Are you Moody, Arrogant, Mild, Agreeable Changeable, Nervous, Suspicious, Easily offended, Quiet, Arguing, Irritating, Lazy etc.

- How do you feel before or during a thunderstorm?

- Do you like being consoled during your tough times?
- Are you sensitive to external stimuli like smell, noise, light etc?

- Do you have any typical habit or gesture like nail biting, causeless
Weeping, talking to one self etc?

- How do you feel about your friends, family, your children and especially your husband / wife?

11. What are your fears and do you dream of any situation repeatedly?


12. What do you crave for in food items and what are your aversions?

13. How is your thirst: Less, Normal or Excessive?

Ans- Less

14. How is your hunger: Less, Normal or Excessive?

A- Normal

15.
15. Is there any kind of food which your body can’t stand?

A-No

16. Is your sweat normal or less or more? Where does it sweat more: Head, Trunk or Limbs?

Ans-Less and mainly on limbs

17. How is your bowel movement and stool type?

Ans- It is normal and never had any problems.

18. How well do you sleep? Do you have a particular posture of sleeping?

Ans-I sleep in small breaks cos i get disturbed by my to do lists and i always think something is pending.

21. What medications have been taken earlier by you to treat the diseases and do you have any particular symptom surfacing after the medication?

Ans- Cal fluor 30

22. What major diseases are running in your family?

Ans- High bp

Gender: Male
Age: 28
Body Type: average
Height: 5'7'
Weight: 69 kg
General appearance: normal
Have you used homeopathic medicines before? If so what, and what homeopathic potencies did you use?

+
None

Please answer the following questions in a descriptive manner after careful analysis and recollection of previous experiences and happenings.

1. Describe your main suffering?
weight suddenly increased from 64 to 69 with 2 inch increase in waist
2. What other physical sufferings do you have in your body?
None
3. What mental sufferings / feelings do you have associated with your physical sufferings?
None
4. What exactly do you feel when you are at your worst? Describe the sensation in your own words.
well i dont take things too hard on me
5. When did it all start? Can you connect it to any past event or disease?
it starts from september 2010
6. Which time of the day you are worst?
None
7. What are the things which aggravate your suffering and which are those which ameliorate the same? Example- time, temperature, pressure, rubbing, washing, eating, tight clothing etc.

None
8. Do your think your sufferings have relation to any external stimuli (like, change of place) or any internal biological changes in the body, like, menses (in females)?
No
9. When do you feel better, during hot weather or cold weather, humid or dry weather?
Nil
10. Describe your general mental set up? Are you Moody, Arrogant, Mild, Agreeable Changeable, Nervous, Suspicious, Easily offended, Quiet, Arguing, Irritating, Lazy etc.
agreeable and changable
- How do you feel before or during a thunderstorm?
Normal
- Do you like being consoled during your tough times?
yes
- Are you sensitive to external stimuli like smell, noise, light etc?
a little bit
- Do you have any typical habit or gesture like nail biting, causeless
Weeping, talking to one self etc?
no
- How do you feel about your friends, family, your children and especially your husband / wife?
well i always feel good when i am with them
11. What are your fears and do you dream of any situation repeatedly?
None

12. What do you crave for in food items and what are your aversions?
Nil
13. How is your thirst: Less, Normal or Excessive?
Normal
14. How is your hunger: Less, Normal or Excessive?
Normal
15. Is there any kind of food which your body can’t stand?
i dont know
16. Is your sweat normal or less or more? Where does it sweat more: Head, Trunk or Limbs?
normal
17. How is your bowel movement and stool type?
normal
18. How well do you sleep? Do you have a particular posture of sleeping?
sleep 7 hours and sleep on one side
19. Do you think you are able to satisfy your sexual desires in general?
yes
20. Do you have any strange, peculiar or unusual symptom or feelings? How are you different from others?
none
21. What medications have been taken earlier by you to treat the diseases and do you have any particular symptom surfacing after the medication?
i am using currenlty the following and and will check it after a month.
1. chelidonium Q 30ml
10 drops thrice in aday
2. Syzygium Jambolanum Q 1o drops thrice in ad ay
3. Nat Sulph 6x 4 tab thrice in aday...
22. What major diseases are running in your family?
nothing
23. Describe, how do you look like? Describe your overall appearance.
(For Females)
24. If your menstrual cycles are not normal, please describe the irregularities, like pains, moods, flow type, clots etc.

25. What major diseases have you had in your life and when. Please write them in a chronological manner.

Gender: Male
Age: 27
Body Type: average
Height: 5'8'
Weight: 75 kg
General appearance:Normal
Have you used homeopathic medicines before? If so what, and what homeopathic potencies did you use?
+
Natrum Mur 1M, Carbo Veg 30, Rus Tox 200.


Please answer the following questions in a descriptive manner after careful analysis and recollection of previous experiences and happenings.

1. Describe your main suffering?
- I had acidity/alsar during childhood and was treated for same using allopathy. The problem had disappeared and has reappeared since last year.
- I had mild constipation problem for the past 10 years but it has also increased since past 4 years.
- People have observed that when I am sleeping I am grinding my teeth, apart from this when I wake up in the morning I find the teeth impression at the front of the tounge, its like the tounge has been pushing against the back teeth wall whole night.
- In the morning after the sleep my hair is twisted in all direction and there is mild pain in the scalp, its like my hair roots are paining. This is not on daily basis but once in a week or so, maybe when i am stressed out a lot, this is been there for the last 4 years.
- There has been a steady increase in the rate of my hair fall for the past 8 years and the density has reduced a lot now and the scalp is almost visible in most of the places now with some patches.
- I wear spectacles and there has also been on increase in the power of glass used gradually every year. It has worsened more in last 8 years.
- I have mild upper back pain now and then and my neves get pulled around the neck back if its bit cold climate.
- Usually when i am working my eyes get stained a lot and water flows down from eyes.
- I get tired a lot and I have very less stamina.
- there is slight pain in my jaws now and then, its like my nerves are getting pulled.
- Even after 12 hours of sleep I dont feel fresh and feel very tired.
- Headache is there durning the evenings and night or I got to sleep very late.
- I am currently suffering from pilesfor the last 2 weeks and taking homeopathy medicine for same from yesterday. Dr.reckeweg R13 medicine

2. What other physical sufferings do you have in your body?
- I have mild upper back pain now and then and my neves get pulled around the neck back if its bit cold climate.
- there is slight pain in my jaws now and then, its like my nerves are getting pulled.
- There has been a steady increase in the rate of my hair fall for the past 8 years and the density has reduced a lot now and the scalp is almost visible in most of the places now with some patches.

3. What mental sufferings / feelings do you have associated with your physical sufferings?
- Headache is there durning the evenings and night or I got to sleep very late.


4. What exactly do you feel when you are at your worst? Describe the sensation in your own words.
- all the parts in my body is paining and I feel like removing them to take rest, severe headache and unable to take good deep breadths.

5. When did it all start? Can you connect it to any past event or disease?
- The physical and mental tiredness and other symptoms listed above are there and been increasing for the past 4 years.


6. Which time of the day you are worst?
sometimes evening or early morning.

7. What are the things which aggravate your suffering and which are those which ameliorate the same? Example- time, temperature, pressure, rubbing, washing, eating, tight clothing etc.
- Cold Temperature, any food with meat, late night sleep, standing and working for long hours causes backpain.


8. Do your think your sufferings have relation to any external stimuli (like, change of place) or any internal biological changes in the body, like, menses (in females)?
- Change of weather causes more suffering.

9. When do you feel better, during hot weather or cold weather, humid or dry weather?
mild humid and warm weather, (28C), too hot weather causes rash on my back and cold weather brings body pains

10. Describe your general mental set up? Are you Moody, Arrogant, Mild, Agreeable Changeable, Nervous, Suspicious, Easily offended, Quiet, Arguing, Irritating, Lazy etc.

Bit quiet and mild with laziness at times.

- How do you feel before or during a thunderstorm?
Before thunderstorm pleasant afterwards normal.

- Do you like being consoled during your tough times?
yes

- Are you sensitive to external stimuli like smell, noise, light etc?
No unless I am very tired and exhausted

- Do you have any typical habit or gesture like nail biting, causeless
Weeping, talking to one self etc?
- Nail biting.


- How do you feel about your friends, family, your children and especially your husband / wife?
- Very good when with them.

11. What are your fears and do you dream of any situation repeatedly?
-No particular dreams, worried of my poor health for the past few years.

12. What do you crave for in food items and what are your aversions?
- Like Acidic food( like lemon taste, tamarind)
No Aversions in particular

13. How is your thirst: Less, Normal or Excessive?
- Normal.

14. How is your hunger: Less, Normal or Excessive?
- Normal

15. Is there any kind of food which your body can’t stand?
- Any form of meat causes constipation.

16. Is your sweat normal or less or more? Where does it sweat more: Head, Trunk or Limbs?
- Normal sweating at all parts.

17. How is your bowel movement and stool type?
- at times hard but if vegetarian food is taken then normal.

18. How well do you sleep? Do you have a particular posture of sleeping?
- not relaxed sleep even after sleeping for 12 hours.
- Grinding of teeth during sleep, apart from this when I wake up in the morning I find the teeth impression at the front of the tongue, its like the tongue has been pushing against the back teeth wall whole night.
- In the morning after the sleep my hair is twisted in all direction and there is mild pain in the scalp, its like my hair roots are paining. This is not on daily basis but once in a week or so, maybe when i am stressed out a lot, this is been there for the last 4 years.

19. Do you think you are able to satisfy your sexual desires in general?
- yes but sometimes tired.

20. Do you have any strange, peculiar or unusual symptom or feelings? How are you different from others?
- There is crackling sound from my leg fingers whenever i compress and release them, the unusual thing is it keeps on going as many times i repeat, whereas when same is done on the hands fingers I can get only max 1 in many hours gap.

21. What medications have been taken earlier by you to treat the diseases and do you have any particular symptom surfacing after the medication?
- acidity/alsar during childhood and was treated for same using allopathy. The problem had disappeared and has reappeared since last year.
- NM 1M once every 3 months administered earlier 4 years back to keep my healthy, have stopped this for the past 4 years.
- Had swine flu last year was treated using allopathy medicines and my body pain has been more prominenet now and keeps coming back at regular intervals.
- Was taking hydrostis for acidity/alsar after the allopathy medicines were stopped for 1 year.

22. What major diseases are running in your family?
- Father has low BP, mother has high BP, and high sugar in the family

Please take three doses of Phosphorus 200 as follows and report back after 15 days.

day 1 morning
1st dose

day 1 evening
2nd dose

day 2 morning
3rd dose

One dose means
If the medicine is in pills form 4 pills. Don't touch pills with hand. Use cap of bottle to take pills.
If the medicine is in liquid dilution form, 3-4 drops in some 20 ml water. Sip up slowly.

Please follow homeo restrictions like no coffee, no raw onion/garlic, no strong perfumes, don't eat or drink anything within 30 minutes before or after taking medicine.

*********************

Gender: Male
Age: 27
Body Type: average
Height: 5'8'
Weight: 75 kg
General appearance:Normal
Have you used homeopathic medicines before? If so what, and what homeopathic potencies did you use?
+
Natrum Mur 1M, Carbo Veg 30, Rus Tox 200.


Please answer the following questions in a descriptive manner after careful analysis and recollection of previous experiences and happenings.

1. Describe your main suffering?
- I had acidity/alsar during childhood and was treated for same using allopathy. The problem had disappeared and has reappeared since last year.
- I had mild constipation problem for the past 10 years but it has also increased since past 4 years.
- People have observed that when I am sleeping I am grinding my teeth, apart from this when I wake up in the morning I find the teeth impression at the front of the tounge, its like the tounge has been pushing against the back teeth wall whole night.
- In the morning after the sleep my hair is twisted in all direction and there is mild pain in the scalp, its like my hair roots are paining. This is not on daily basis but once in a week or so, maybe when i am stressed out a lot, this is been there for the last 4 years.
- There has been a steady increase in the rate of my hair fall for the past 8 years and the density has reduced a lot now and the scalp is almost visible in most of the places now with some patches.
- I wear spectacles and there has also been on increase in the power of glass used gradually every year. It has worsened more in last 8 years.
- I have mild upper back pain now and then and my neves get pulled around the neck back if its bit cold climate.
- Usually when i am working my eyes get stained a lot and water flows down from eyes.
- I get tired a lot and I have very less stamina.
- there is slight pain in my jaws now and then, its like my nerves are getting pulled.
- Even after 12 hours of sleep I dont feel fresh and feel very tired.
- Headache is there durning the evenings and night or I got to sleep very late.
- I am currently suffering from pilesfor the last 2 weeks and taking homeopathy medicine for same from yesterday. Dr.reckeweg R13 medicine

2. What other physical sufferings do you have in your body?
- I have mild upper back pain now and then and my neves get pulled around the neck back if its bit cold climate.
- there is slight pain in my jaws now and then, its like my nerves are getting pulled.
- There has been a steady increase in the rate of my hair fall for the past 8 years and the density has reduced a lot now and the scalp is almost visible in most of the places now with some patches.

3. What mental sufferings / feelings do you have associated with your physical sufferings?
- Headache is there durning the evenings and night or I got to sleep very late.


4. What exactly do you feel when you are at your worst? Describe the sensation in your own words.
- all the parts in my body is paining and I feel like removing them to take rest, severe headache and unable to take good deep breadths.

5. When did it all start? Can you connect it to any past event or disease?
- The physical and mental tiredness and other symptoms listed above are there and been increasing for the past 4 years.


6. Which time of the day you are worst?
sometimes evening or early morning.

7. What are the things which aggravate your suffering and which are those which ameliorate the same? Example- time, temperature, pressure, rubbing, washing, eating, tight clothing etc.
- Cold Temperature, any food with meat, late night sleep, standing and working for long hours causes backpain.


8. Do your think your sufferings have relation to any external stimuli (like, change of place) or any internal biological changes in the body, like, menses (in females)?
- Change of weather causes more suffering.

9. When do you feel better, during hot weather or cold weather, humid or dry weather?
mild humid and warm weather, (28C), too hot weather causes rash on my back and cold weather brings body pains

10. Describe your general mental set up? Are you Moody, Arrogant, Mild, Agreeable Changeable, Nervous, Suspicious, Easily offended, Quiet, Arguing, Irritating, Lazy etc.

Bit quiet and mild with laziness at times.

- How do you feel before or during a thunderstorm?
Before thunderstorm pleasant afterwards normal.

- Do you like being consoled during your tough times?
yes

- Are you sensitive to external stimuli like smell, noise, light etc?
No unless I am very tired and exhausted

- Do you have any typical habit or gesture like nail biting, causeless
Weeping, talking to one self etc?
- Nail biting.


- How do you feel about your friends, family, your children and especially your husband / wife?
- Very good when with them.

11. What are your fears and do you dream of any situation repeatedly?
-No particular dreams, worried of my poor health for the past few years.

12. What do you crave for in food items and what are your aversions?
- Like Acidic food( like lemon taste, tamarind)
No Aversions in particular

13. How is your thirst: Less, Normal or Excessive?
- Normal.

14. How is your hunger: Less, Normal or Excessive?
- Normal

15. Is there any kind of food which your body can’t stand?
- Any form of meat causes constipation.

16. Is your sweat normal or less or more? Where does it sweat more: Head, Trunk or Limbs?
- Normal sweating at all parts.

17. How is your bowel movement and stool type?
- at times hard but if vegetarian food is taken then normal.

18. How well do you sleep? Do you have a particular posture of sleeping?
- not relaxed sleep even after sleeping for 12 hours.
- Grinding of teeth during sleep, apart from this when I wake up in the morning I find the teeth impression at the front of the tongue, its like the tongue has been pushing against the back teeth wall whole night.
- In the morning after the sleep my hair is twisted in all direction and there is mild pain in the scalp, its like my hair roots are paining. This is not on daily basis but once in a week or so, maybe when i am stressed out a lot, this is been there for the last 4 years.

19. Do you think you are able to satisfy your sexual desires in general?
- yes but sometimes tired.

20. Do you have any strange, peculiar or unusual symptom or feelings? How are you different from others?
- There is crackling sound from my leg fingers whenever i compress and release them, the unusual thing is it keeps on going as many times i repeat, whereas when same is done on the hands fingers I can get only max 1 in many hours gap.

21. What medications have been taken earlier by you to treat the diseases and do you have any particular symptom surfacing after the medication?
- acidity/alsar during childhood and was treated for same using allopathy. The problem had disappeared and has reappeared since last year.
- NM 1M once every 3 months administered earlier 4 years back to keep my healthy, have stopped this for the past 4 years.
- Had swine flu last year was treated using allopathy medicines and my body pain has been more prominenet now and keeps coming back at regular intervals.
- Was taking hydrostis for acidity/alsar after the allopathy medicines were stopped for 1 year.

22. What major diseases are running in your family?
- Father has low BP, mother has high BP, and high sugar in the family

oops!!!!
i made the above post by mistake.
i have rigtly posted it at..
http://www.abchomeopathy.com/forum2.php/259741/

Gender: F
Age: 23
Body Type: Slender
Height: 5’3
Weight: 135
General appearance: normal
Have you used homeopathic medicines before?No If so what, and what homeopathic potencies did you use?

+

Please answer the following questions in a descriptive manner after careful analysis and recollection of previous experiences and happenings.

1. Describe your main suffering? I have herpes type 2, I had the first primary breakout, but I want to have sex with others without having to worry about transmitting and I want this virus dead and gone from my body.

2. What other physical sufferings do you have in your body? None

3. What mental sufferings / feelings do you have associated with your physical sufferings? Anxiety depression tiredness

4. What exactly do you feel when you are at your worst? Describe the sensation in your own words.
depressed, suicidal, sad, angry
5. When did it all start? Can you connect it to any past event or disease? I had unprotected sex with someone who said they don’t have any std’s

6. Which time of the day you are worst? mornings

7. What are the things which aggravate your suffering and which are those which ameliorate the same? Example- time, temperature, pressure, rubbing, washing, eating, tight clothing etc. rubbing, pressure


8. Do your think your sufferings have relation to any external stimuli (like, change of place) or any internal biological changes in the body, like, menses (in females)? Yes, I have the implanon birth control implant in my arm, so that might have added to the cause of my problems, also I ate junk food and drank lots of sodas, not exercise.

9. When do you feel better, during hot weather or cold weather, humid or dry weather? Dry weather

10. Describe your general mental set up? Are you Moody, Arrogant, Mild, Agreeable Changeable, Nervous, Suspicious, Easily offended, Quiet, Arguing, Irritating, Lazy etc. moody, agreeable, changeable, nervous, suspicious, easily offended, quiet, arguing, lazy

- How do you feel before or during a thunderstorm? I feel calm before and after.

- Do you like being consoled during your tough times? Yes
- Are you sensitive to external stimuli like smell, noise, light etc? Smell, noise, and light.

- Do you have any typical habit or gesture like nail biting, causeless
Weeping, talking to one self etc? yes causeless weeping, I talk to myself sometimes.

- How do you feel about your friends, family, your children and especially your husband / wife? I feel like my family is not supportive in what I do.

11. What are your fears and do you dream of any situation repeatedly? My fears are being rejected, alone, in pain, suffering, and I dream of being in a loving fulfilling relationship and to get out of my family situation.


12. What do you crave for in food items and what are your aversions? I crave for cheese, hot dogs, fries, pizza, cake, fries, junk food basically. Cookies also, pepsi. Sometimes pineapple.

13. How is your thirst: Less, Normal or Excessive? Depends sometimes excessive at night and less in mornings and in the day time normal. After eating salty foods excessive also after walks.

14. How is your hunger: Less, Normal or Excessive? It is excessive.

15. Is there any kind of food which your body can’t stand? Spicey foods.

16. Is your sweat normal or less or more? Where does it sweat more: Head, Trunk or Limbs? Normal. Trunk.

17. How is your bowel movement and stool type? My bowel movement is loose now. It used to be formed.

18. How well do you sleep? Do you have a particular posture of sleeping? I sleep at around 12 pm to 8 or 9 am. I like sleeping on my back and right side.

19. Do you think you are able to satisfy your sexual desires in general? Yes.

20. Do you have any strange, peculiar or unusual symptom or feelings? How are you different from others? No. I am very introverted and quiet and don’t like crowds and I keep to myself in public situations.

21. What medications have been taken earlier by you to treat the diseases and do you have any particular symptom surfacing after the medication? I took cystex initially which did not help with the trouble urination. Then I tried the D-Mannose. Then I took CIPROFLOXACIN for about a week and PHENAZOPRIDINE also. I am taking olive leaf extract in tablet form, oil of oregano under my tounge and rub on my lower back to kill the virus and Lysine tablets to boost immune system and a multivitamin.

22. What major diseases are running in your family? None.

23. Describe, how do you look like? Describe your overall appearance.
(For Females) I have brown hair brown eyes. Light skin, Retainers for my braces.
24. If your menstrual cycles are not normal, please describe the irregularities, like pains, moods, flow type, clots etc. I have implanon birth control so it changed my flow. Now it is very heavy flow. Before it lasted 4-5 days. It was only heavy the first 3 days. Now I don’t know how long it will last.

25. What major diseases have you had in your life and when. Please write them in a chronological manner. None.

Gender: Male
Age: 26
Body Type: slim and smart
Height: 5.11
Weight: 65kg
General appearance: normal. colour fare and attractive :)
Have you used homeopathic medicines before? If so what, and what homeopathic potencies did you use?
ans: No
+

Please answer the following questions in a descriptive manner after careful analysis and recollection of previous experiences and happenings.

1. Describe your main suffering? .
ans: Digestion problem Gass in Stomach, many white droops observes when go close girl friend when goes close to girl friend and these droops observed while Bowel Movements , and very less intercourse timmings

2. What other physical sufferings do you have in your body?
and: not much

3. What mental sufferings / feelings do you have associated with your physical sufferings?
and: sex phobia a bit

4. What exactly do you feel when you are at your worst? Describe the sensation in your own words.
and: once i was kissing my girl friend i observed many droops on my underwear after that. and whenever i feel eraction in instrument it release droops

5. When did it all start? Can you connect it to any past event or disease?
and: i dont remember

6. Which time of the day you are worst?
and: all the time

7. What are the things which aggravate your suffering and which are those which ameliorate the same? Example- time, temperature, pressure, rubbing, washing, eating, tight clothing etc.


8. Do your think your sufferings have relation to any external stimuli (like, change of place) or any internal biological changes in the body, like, menses (in females)?
and: NO
9. When do you feel better, during hot weather or cold weather, humid or dry weather? its same through out the year
and:

10. Describe your general mental set up? Are you Moody, Arrogant, Mild, Agreeable Changeable, Nervous, Suspicious, Easily offended, Quiet, Arguing, Irritating, Lazy etc. am Hard working, confident, and bit sleepy

- How do you feel before or during a thunderstorm?
ans: Normal

- Do you like being consoled during your tough times?
ans: nope
- Are you sensitive to external stimuli like smell, noise, light etc?
ans: yap some times

- Do you have any typical habit or gesture like nail biting, causeless
Weeping, talking to one self etc?
ans: some times talks with my self

- How do you feel about your friends, family, your children and especially your husband / wife?
ans: i am very much blessed in case of friends and family. a have vast circle of loving people around me. Not married yet

11. What are your fears and do you dream of any situation repeatedly?
ans: not any fear


12. What do you crave for in food items and what are your aversions?
ans: i like all kind of food and dont dislike anything. but tries to avoids some fatts now becuase it takes time in digestion

13. How is your thirst: Less, Normal or Excessive?
ans: Normal

14. How is your hunger: Less, Normal or Excessive?
ans: normal

15. Is there any kind of food which your body can’t stand?
ans: none

16. Is your sweat normal or less or more? Where does it sweat more: Head, Trunk or Limbs?

17. How is your bowel movement and stool type?
ans: Bowel moment is very unusaal. many times it comes after two or three days. and stool type is dry hard and uneasy to release.


18. How well do you sleep? Do you have a particular posture of sleeping?
ans: i can awake as long as i want more than 48 hours but once i sleep its really hard for me to get up. i remain completlty senseless while sleeping and normal sleeping time is 9 or 10 houurs in averge.

19. Do you think you are able to satisfy your sexual desires in general?
ans: i am not married yet. done masternation in teenage with the average to once in a week almsost. since last few year i had not done anything like this or had sex. but when i goes close to girl friend i observes that i had droops on my underwear. once i had sex and observed very little intercourse timming

20. Do you have any strange, peculiar or unusual symptom or feelings? How are you different from others?
ans: not so
21. What medications have been taken earlier by you to treat the diseases and do you have any particular symptom surfacing after the medication?
ans: nothing yet infact i have taken it serioulsy and keep my self busy in studies and carreer. but now i think m going to be married in next year so i have to treeat my self
22. What major diseases are running in your family?

23. Describe, how do you look like? Describe your overall appearance.
ans: i fare looking guy. slim n smart. chest and mascless are not well shaped. perfact height etc.
(For Females)
24. If your menstrual cycles are not normal, please describe the irregularities, like pains, moods, flow type, clots etc.

25. What major diseases have you had in your life and when. Please write them in a chronological manner.
ans: i had infaction of tubercloses (TB) twise in my life at the age to 15 and 17. once suffered jundos last year nothing more

Gender: Female
Age: 19 yr
Body Type: slightly heavy and muscular
Height: 5 ft 5 inch
Weight: 151 lbs
General appearance: attractive, curvy figure
Have you used homeopathic medicines before? If so what, and what homeopathic potencies did you use? No never

+

Please answer the following questions in a descriptive manner after careful analysis and recollection of previous experiences and happenings.

1. Describe your main suffering? Hashimoto’s thyroiditis

2. What other physical sufferings do you have in your body? White spots on all nail except thumb, need to lose few pounds, low stomach acid , adrenal fatigue…have worn glasses since age 3 due to cross eyes….mild issue

3. What mental sufferings / feelings do you have associated with your physical sufferings? Frustrated that cant lose weight and that I have to take meds all the time…tired of thinking about it all the time and wishing I did not have to take medicine for rest of my life.

4. What exactly do you feel when you are at your worst? Describe the sensation in your own words. Lethargic, apathy, tired, unmotivated….when at my very worst BEFORE meds I felt very anxious and slow moving…but don’t feel that when on meds

5. When did it all start? Can you connect it to any past event or disease? I think it started when I was about 12 with anxiety attacks, for no reason…think that was beginning of the thyroid failure…I also had bad breath when a young girl in school…this was in spite of good hygiene and no infection….so wonder if low stomach acid was issue as young girl..

6. Which time of the day you are worst? Feel good all day on my meds but worst time used to be in the mornings

7. What are the things which aggravate your suffering and which are those which ameliorate the same? Example- time, temperature, pressure, rubbing, washing, eating, tight clothing et feel worst when I stay up too late at night…

8. Do your think your sufferings have relation to any external stimuli (like, change of place) or any internal biological changes in the body, like, menses (in females)? No I have irregular menses so I cannot make any connection with that…

9. When do you feel better, during hot weather or cold weather, humid or dry weather? Feel same in all temperatures but don’t iike humidity

10. Describe your general mental set up? Are you Moody, Arrogant, Mild, Agreeable Changeable, Nervous, Suspicious, Easily offended, Quiet, Arguing, Irritating, Lazy etc. ….i am agreeable, mature, type a personality, sometimes nervous

- How do you feel before or during a thunderstorm? Same either time

- Do you like being consoled during your tough times? yes
- Are you sensitive to external stimuli like smell, noise, light etc? no I can sleep through all of it

- Do you have any typical habit or gesture like nail biting, causeless
Weeping, talking to one self etc? some teeth grinding at night

- How do you feel about your friends, family, your children and especially your husband / wife? Good feelings about family and friends …except one friend with whom I have negative feelings

11. What are your fears and do you dream of any situation repeatedly? No repeated dreams, don’t remember dreams very often.


12. What do you crave for in food items and what are your aversions? Crave coffee ice cream, like carbohydrate a lot…. hate sea food

13. How is your thirst: Less, Normal or Excessive? normal

14. How is your hunger: Less, Normal or Excessive? normal

15. Is there any kind of food which your body can’t stand? Sea food

16. Is your sweat normal or less or more? Where does it sweat more: Head, Trunk or Limbs? Head and limbs

17. How is your bowel movement and stool type? Normal bowel movements, stool brown and normal

18. How well do you sleep? Do you have a particular posture of sleeping? Sleep well often on back

19. Do you think you are able to satisfy your sexual desires in general? yes

20. Do you have any strange, peculiar or unusual symptom or feelings? How are you different from others? More mature than others my age, more responsible, less desire to party than others my age, a homebody,

21. What medications have been taken earlier by you to treat the diseases and do you have any particular symptom surfacing after the medication? I take naturethroid for my thyroid, isocort for my adrenal fatigue, betaine hcl for low stomach acid, and lots of vitamins and supplements

22. What major diseases are running in your family? Hashimoto thyroiditis, asthma, allergies

23. Describe, how do you look like? Describe your overall appearance. Statuesque…nice hair and face, muscular, large thighs, brown eyes, gold hair, tiny nose,
(For Females)
24. If your menstrual cycles are not normal, please describe the irregularities, like pains, moods, flow type, clots etc. Irregular cycles, sometimes only 21 days, sometimes 32 days….i suspect there is NO ovulation or not regular ovulation,

25. What major diseases have you had in your life and when. Please write them in a chronological manner anxiety attacks at age 12 that were treated with st johns wort and passionflower…they went away after that…then at age 16 I was diagnosed with hashimoto thyroiditis…..and at age 19 diagnosed with adrenal fatigue and low stomach acid…as a very young child my mother noted I had very bad breath for a little girl..i just remembered that.

Gender: Female
Age: 37
Body Type: Petite
Height: 5’2
Weight: 120
General appearance: Petite, light olive skinned, dark hair and eyes.
Have you used homeopathic medicines before? If so what, and what homeopathic potencies did you use? Not really

+

Please answer the following questions in a descriptive manner after careful analysis and recollection of previous experiences and happenings.

1. Describe your main suffering? Fatigue/Drowsiness

2. What other physical sufferings do you have in your body? Fibromyalgia and tmj. Main symptoms: neck pain, sinus pain, mild muscular pain. My Fibro has been mostly under control for years. Seasonal allergies that sometimes cause sinus pain and nausea.

3. What mental sufferings / feelings do you have associated with your physical sufferings? I’m a very upbeat, bubbly person but of course have my occasional pity parties when I’m feeling badly. I get scared I will have to live with the fatigue forever and how I’ll do it and I worry about my kids health a lot.

4. What exactly do you feel when you are at your worst? Describe the sensation in your own words. I feel so drowsy I can’t keep my eyes open. I feel a floating/tingly sensation and can’t concentrate.

5. When did it all start? Can you connect it to any past event or disease? Started at the beginning of September 2010. Doctor thinks it’s related to a sore throat I had for a couple months back in May/June 2010

6. Which time of the day you are worst? Afternoon or evening, depending on the day

7. What are the things which aggravate your suffering and which are those which ameliorate the same? Example- time, temperature, pressure, rubbing, washing, eating, tight clothing etc.

Strong smells make it worse, heat seems to make me drowsier too
8. Do your think your sufferings have relation to any external stimuli (like, change of place) or any internal biological changes in the body, like, menses (in females)? I feel like my thyroid might be off but doctor says it’s fine

9. When do you feel better, during hot weather or cold weather, humid or dry weather? Cold makes me feel more awake

10. Describe your general mental set up? Are you Moody, Arrogant, Mild, Agreeable Changeable, Nervous, Suspicious, Easily offended, Quiet, Arguing, Irritating, Lazy etc.
I’m very out-going, bubbly, emotional and impatient

- How do you feel before or during a thunderstorm? Same as usual

- Do you like being consoled during your tough times? Yes, by my husband only
- Are you sensitive to external stimuli like smell, noise, light etc? perfume smells, light

- Do you have any typical habit or gesture like nail biting, causeless
Weeping, talking to one self etc? no

- How do you feel about your friends, family, your children and especially your husband / wife? I enjoy my friends. Love my children though they are a handful and I am more impatient with than I’d like to be. I wish I could relax with them and enjoy them more. I worry for their health always. My husband is wonderful. He is very supportive and nurturing when I need it. He helps me take each day as it comes and not worry too much about the “what ifs”

11. What are your fears and do you dream of any situation repeatedly? I fear losing one of my children and worry for their and my husbands health.


12. What do you crave for in food items and what are your aversions? I crave salt a lot but then immediately crave something sweet to offset it.

13. How is your thirst: Less, Normal or Excessive? Normal I think

14. How is your hunger: Less, Normal or Excessive? Erratic. Some days I’m not too hungry but lately I have days where I don’t feel like I get full and feel shaky. Am gaining weight because I’m too tired to exercise.

15. Is there any kind of food which your body can’t stand? No

16. Is your sweat normal or less or more? Where does it sweat more: Head, Trunk or Limbs? Normal. Trunk

17. How is your bowel movement and stool type? Have about 2-4 bowel movements a day. Light colored, long and thin.

18. How well do you sleep? Do you have a particular posture of sleeping? Mostly ok. I wake1-2 times to go to the bathroom. Usually sleep on my side with a pillow between my knees

19. Do you think you are able to satisfy your sexual desires in general? Yes

20. Do you have any strange, peculiar or unusual symptom or feelings? How are you different from others? No

21. What medications have been taken earlier by you to treat the diseases and do you have any particular symptom surfacing after the medication? I’ve tried Olive leaf Extract. Take Magnesium and Malic Acid for Fibro. Currently trying Coconut oil.

22. What major diseases are running in your family? None that I know of

23. Describe, how do you look like? Describe your overall appearance. Petite. Size 6. Pretty.
(For Females)
24. If your menstrual cycles are not normal, please describe the irregularities, like pains, moods, flow type, clots etc. Usually only have 4/year but lately have been more regular. Last about 7 days with 2-3 heavy, cramping days

25. What major diseases have you had in your life and when. Please write them in a chronological manner.
Fibromyalgia and TMJ diagnosed in 2000

Gender: female
Age: 2years
Body Type: smal
Height:
Weight:27lb
General appearance:cuteeee
Have you used homeopathic medicines before? If so what, and what homeopathic potencies did you use?
No
+

Please answer the following questions in a descriptive manner after careful analysis and recollection of previous experiences and happenings.

1. Describe your main suffering?
High BG
2. What other physical sufferings do you have in your body?
so far none
3. What mental sufferings / feelings do you have associated with your physical sufferings?
crankyy
4. What exactly do you feel when you are at your worst? Describe the sensation in your own words.
want to eat more and cry alot
5. When did it all start?
Can you connect it to any past event or disease?
when she was 14 month old
6. Which time of the day you are worst?
from 12 pm to 8 pm really high
7. What are the things which aggravate your suffering and which are those which ameliorate the same? Example- time, temperature, pressure, rubbing, washing, eating, tight clothing etc.

eating
8. Do your think your sufferings have relation to any external stimuli (like, change of place) or any internal biological changes in the body, like, menses (in females)?
no
9. When do you feel better, during hot weather or cold weather, humid or dry weather?
dont know
10. Describe your general mental set up? Are you Moody, Arrogant, Mild, Agreeable Changeable, Nervous, Suspicious, Easily offended, Quiet, Arguing, Irritating, Lazy etc.
dont know

- How do you feel before or during a thunderstorm?

dont know
- Do you like being consoled during your tough times?
- Are you sensitive to external stimuli like smell, noise, light etc?

- Do you have any typical habit or gesture like nail biting, causeless
Weeping, talking to one self etc?

- How do you feel about your friends, family, your children and especially your husband / wife?

11. What are your fears and do you dream of any situation repeatedly?


12. What do you crave for in food items and what are your aversions?
every thing
13. How is your thirst: Less, Normal or Excessive?
normal
14. How is your hunger: Less, Normal or Excessive?
she is too young so can tell.
15. Is there any kind of food which your body can’t stand?

16. Is your sweat normal or less or more? Where does it sweat more: Head, Trunk or Limbs?

17. How is your bowel movement and stool type?
some time hard.
18. How well do you sleep?
Do you have a particular posture of sleeping?

19. Do you think you are able to satisfy your sexual desires in general?

20. Do you have any strange, peculiar or unusual symptom or feelings? How are you different from others?

21. What medications have been taken earlier by you to treat the diseases and do you have any particular symptom surfacing after the medication?
she is on humalog insuline.
22. What major diseases are running in your family?
none
23. Describe, how do you look like? Describe your overall appearance.
(For Females)
24. If your menstrual cycles are not normal, please describe the irregularities, like pains, moods, flow type, clots etc.

25. What major diseases have you had in your life and when. Please write them in a chronological manner.

Gender:Male
Age:32
Body Type:Slim
Height:5'7
Weight:75
General appearance:
Have you used homeopathic medicines before? If so what, and what homeopathic potencies did you use?
i used many medicines but its not usefull
+

Please answer the following questions in a descriptive manner after careful analysis and recollection of previous experiences and happenings.

1. Describe your main suffering?
he problem is premature ejaculation & early discharge..

i do lot of masturbation in my past life.i discharge only one stock.and some time i discharge with out discharge.
my ejaculation timing is very soon.my penis is bent too much towards left and is become weak too.my penis frenulum is very sensitive.

2. What other physical sufferings do you have in your body?

3. What mental sufferings / feelings do you have associated with your physical sufferings?

4. What exactly do you feel when you are at your worst? Describe the sensation in your own words.

5. When did it all start? Can you connect it to any past event or disease?

6. Which time of the day you are worst?

7. What are the things which aggravate your suffering and which are those which ameliorate the same? Example- time, temperature, pressure, rubbing, washing, eating, tight clothing etc.


8. Do your think your sufferings have relation to any external stimuli (like, change of place) or any internal biological changes in the body, like, menses (in females)?

9. When do you feel better, during hot weather or cold weather, humid or dry weather?

10. Describe your general mental set up? Are you Moody, Arrogant, Mild, Agreeable Changeable, Nervous, Suspicious, Easily offended, Quiet, Arguing, Irritating, Lazy etc.

- How do you feel before or during a thunderstorm?

- Do you like being consoled during your tough times?
- Are you sensitive to external stimuli like smell, noise, light etc?

- Do you have any typical habit or gesture like nail biting, causeless
Weeping, talking to one self etc?

- How do you feel about your friends, family, your children and especially your husband / wife?

11. What are your fears and do you dream of any situation repeatedly?


12. What do you crave for in food items and what are your aversions?

13. How is your thirst: Less, Normal or Excessive?

14. How is your hunger: Less, Normal or Excessive?

15. Is there any kind of food which your body can’t stand?

16. Is your sweat normal or less or more? Where does it sweat more: Head, Trunk or Limbs?

17. How is your bowel movement and stool type?

18. How well do you sleep? Do you have a particular posture of sleeping?

19. Do you think you are able to satisfy your sexual desires in general?

20. Do you have any strange, peculiar or unusual symptom or feelings? How are you different from others?

21. What medications have been taken earlier by you to treat the diseases and do you have any particular symptom surfacing after the medication?

22. What major diseases are running in your family?

23. Describe, how do you look like? Describe your overall appearance.
(For Females)
24. If your menstrual cycles are not normal, please describe the irregularities, like pains, moods, flow type, clots etc.

25. What major diseases have you had in your life and when. Please write them in a chronological manner.
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Re: New Homeopathy Patient Intake Form From Homeopathy International 1 on 2010-12-31
bump.
Report post to moderator

Re: New Homeopathy Patient Intake Form From nawazkhan on 2010-12-31
Dear JH,

HAPPY NEW YEAR!

Well, I use this form that may require usual enhancement or you may take some additional items from this and implement in your form.

Please keep up the good work. You efforts are greatly appreciated!

1. ID
2. Age
3. Sex
4. Single/Married
5. weight
6. Height ….
7. country
8. climate
9. List of your complaints

10. Since how long are you suffering from each complaint

11. Diabetic or non-Diabetic
12. Desire sweets/sour/salt
13. Thirst
14. Tongue and Taste
15. Current BP (without medicine and with medicine)

16. What exactly is happening?

17. How do you feel?
18. How does this affect you?

19. How does it feel like?
20. What comes to your mind?
21. One situation that had a
big effect on you?

22. How did that feel like?
23. What sensation do you experience in that situation?

24. What are you showing by that gesture of your hand (Habits or Actions)?
25. Current medicines you are taking?

26. Family Background
27. Educational Qualifications of the patient

28. Nature of work, what do you do for living?

29. Desires, likes and dislikes for food

30. Name of foods which increase your problem

31. Mind-behavior, anger, irritability, hurry, impatient…and so on.. How are you different from other persons, public speaking or not , you can describe all of the details about your behavior, love and affections.

32. Aggravation (increases-time, season,)& Amelioration (Decreases)

33. Attached here your photographs of the affected area. (if required/optional)

34. Location of the disease
35. Side of the problem (Right or Left), (Upper or Lower part of body)

36. Color of the secretions/discharges e.g urine, stool, sputum, Saliva etc.

May God Bless You?

Regards
Nawaz