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DR ANUTOSH CHAKRABORTY'S Expert Homeopathy [A
Clinic of Advanced Pain Solution and Chronic Disease]
(FULLY CONFIDENTIAL)
31/1D, Sisir Bagna
Road, Behala, Kolkata-700034, West Bengal, India
CASE TAKING FORM
THIS CASE TAKING FOR THE CHRONIC
DISEASE WHO ARE SUFFERING FROM LONG TIME AND DOES NOT GET SATISFACTION
WELCOME TO THE WORLD OF HOMEOPATHY
& EXPERIENCE GENTLE, RAPID AND
LONG-LASTING RELIEF/RELIEF!!
Don’t you think you have a right to live a healthy and happy life??
Read & Reply to every point
carefully, because it concerns YOU.
All details are confidential and limited only to
people who really care for health.
Kindly remember, the
quality of treatment or result that we provide to you depends entirely on the
quality of the information that we receive from you through the form. (Since we
are not seeing each other face-to-face)
Investing 1 – 2
hours of your valuable time will help secure your lifelong health!!
If you think it
is too much to do in one attempt, do it in parts but with full concentration
and commitment
HELP US TO HELP YOU BETTER!!
PERSONAL DETAILS
1. NAME:
2. SEX:
3. AGE:
4. ADDRESS WITH CONTACT NO:
5. BIRTHPLACE:
6. OCCUPATION:
HISTORY OF PRESENT
ILLNESS:
Describe your present complaint Include the location, which part is
affected? E.g.: Right forehead, lower abdomen, etc.
a) Describe the type of
pain or sensation of discomfort that you feel. E.g.: Burning
sensation, cramping pain, tingling, numbness, tightness, coldness, etc.
b) How did the problem begin (origin)? What could
be the probable cause? E.g.: After exposure to cold wind, after eating
oily food, after the loss of job, etc.
c) How long has the problem been
there (duration)? E.g.: 2 days, 4 weeks, 8-10 years, etc.
d) What is the progress of the symptoms
since they began? Have they become worse or better? If yes, how fast or slow?
Have they spread to other parts?
E.g.: Started with a right-sided headache 4 days ago. Later, spread to the left side 2 days ago. Developed nausea after eating yesterday. Today, there is
also, pain in the right ear.
e) What
factors aggravate or worsen your symptoms? Eg: By applying
heat or cold; by resting the part or moving it; after sleep; in a closed room;
Sun exposure, etc. (This info is very important for treatment – so think
carefully and reply)
f) What
factors ameliorate your symptoms or make you feel better?
E.g.: Applying pressure; Massage; Heat or Ice; lying down; keeping the mind
busy; etc
g) Are your symptoms worse or better at
any particular time? Eg: Worse at 11 a.m.; better in the evening; worse
between 4 and 8 pm; better at night; etc. Are your symptoms worse in
any particular season? E.g.: “Joint pains occurring in the winter season,
better in summer”; “Annual eczema in December”
h) Any other comment …
7. DISCOMFORTSOTHER ASSOCIATED OR COMPLAINTS:
Describe all other complaints besides the main complaint.
Describe each one in the same manner as you describe the primary complaint.
(Describe everything that bothers you at length)
E.g.: Headache associated with cramping pain in the abdomen.
8. PAST
HISTORY: History of any major illness,
injury, or operation in the past. Describe its impact on you &at what age
you had it?
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Illnesses suffered in the past E.g.: Tuberculosis, Typhoid, Malaria, Jaundice, Ring-worm, Urticaria,
Measles, Mumps, Herpes, Chicken-pox, etc… |
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Injuries E.g.: Fractures, wounds, bites, etc. |
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Surgeries E.g.: Removal of appendix or tonsils or uterus, etc; plating of
fracture, etc |
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Any other significant history |
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9. FAMILY HISTORY: History of major illnesses in other family members such as parents, siblings, grandparents, cousins, uncles, aunts, etc.) E.g.: Grandparent with history of diabetes OR Maternal aunt with history of Schizophrenia(mention their present age and more details)
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DISEASE NAME |
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Asthma |
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Allergies |
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Heart Disease |
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Cancer |
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Diabetes |
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Hypertension |
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Stroke/Paralysis |
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Tuberculosis |
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Any other disease |
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OCCUPATIONAL HISTORY: Type
of occupation and what stresses are placed on you by this employment.
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Office □Factory □ Hotel □ Shop □ Self-employed□ Other: |
9. HABITS:(Please
specify the quantity, frequency & duration) Eg: Smoking 4 cigarettes a day
for the last 2 years.
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Smoking |
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Chewing Tobacco / Pan |
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Pan Masala |
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Alcohol |
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Recreational Drugs |
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Any other peculiar habit E.g.: Frequent hand washing, repeatedly checking door at night, nail
biting, eating indigestible things like chalk, slate, mud, etc. |
PERSONAL/SOCIAL
HISTORY:
a) RESIDENCE
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Describe the area in brief E.g.: Flat on 5th floor of an apartment in
resident-cum-commercial complex |
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Pollution type E.g.: Air pollution, water pollution |
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Pollution level or grade |
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The climate in the area Mostly dry, mostly humid, extreme summers and winters, etc |
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Do you have any pets? Specify E.g.: German Shepherd dog, Persian cat, tortoise, rabbit, etc. |
b) FAMILY
SETUP WITH DETAILS OF EACH FAMILY MEMBER
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Name |
Age |
Relation |
Work |
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GENERAL HISTORY:
c) APPETITE:
d) FOOD ALLERGIES: Are you allergic to any specific food? E.g.: seafood, peanuts, eggs, wheat, milk, etc.
e) CRAVINGS: What types of food or
tasted do you like very much e.g. Sweets, Salty,
Spicy,
Eggs, Fish, Curds, Fruits, etc.? To what intensity or degree? Any
particular taste that you desire strongly? E.g.: Raw, Cooked, Warm, Sweet,
Sour, Salty, Spicy, Bitter, etc. Do you add extra salt to your food? Eg:
“I have sweets even after meals”; “I must have something sweet”; “I always add
extra salt to my food”. What temperature of food do you prefer? E.g.: “My food
must be hot. I can’t eat it once it becomes cold.”
I have the following unique Cravings:-
f) AVERSIONS: What type of food
or taste do you particularly dislike or detest? To what intensity or degree?
Any food that doesn’t suit you or causes any trouble? E.g.: Aversion to
milk dislikes meat, intolerance to eggs, aversion to sour foods, etc.: “I
can’t even have one drop of milk since childhood” OR “If I have an egg, I
develop rashes all over my body.”
(For intensity, grade from 1 to 3 where 1 stands for minimum and 3 for
maximum intensity)
IF Hungry: I hate Cold Foods, Cold drinks, or small-time passes snacks.
Hate Intensity: 3
g) THIRST: How much water do you consume in a
day? How much at a time? At what intervals? Do you prefer your water at room
temperature or hot or cold?
E.g.: Thirst for small quantities of cold water frequently. Drink about
1.5 litters in a day.
h) STOOL: Are your bowel movements regular? How many
times a day do you pass motions? Any difficulty or pain while passing motions?
Do you pass any blood or mucus in the stool? Any peculiar smell? Do you have
constipation or loss motions? Any other issues related to stools or bowel
movements? Do you feel fresh after passing motions?
Eg: Straining for stool with occasional bright red blood. “I have
regular motions twice a day” OR “I pass a stool after 3 days – I am severely
constipated.”
i) URINE: How many times a day do you pass
urine on an average? Any difficulty while passing urine? What is the color of
the urine? Any peculiar smell to the urine? Any other issues related to urine
or urination? Any burning, itching, or other abnormal sensation?
E.g.: Urine dark brown in color since 3 days with fishy smell passed 7
to 8 times in the day and 2 to 3 times at night.
j) PERSPIRATION: How much do you
perspire? Do you perspire more on any particular part/parts of the body? Eg:
Armpits, forehead, palms, soles, etc. Does it occur at any particular time or
is it related to any particular activity? E.g.: At night, after meals. Does it
stain your clothes? Any peculiar smell?
E.g.: “I have excessive sweating especially on the neck and palms after
slight exertion” OR “My sweat smells like garlic” OR “Sweat leaves yellow
stains on white clothes”
k) THERMALS: Do
you feel uncomfortable in a hot or cold climate? Does sun exposure/fan
exposure/AC exposure affect your health & how? Which season do you
like the best? In which season does your complaint get worse or better? Do you
prefer to cover yourself while sleeping at night or not? Do you prefer the
fan/AC or not?
E.g.: I prefer
winters with AC on during summers. Cannot tolerate direct sun exposure. Need a thin blanket to cover during the night.
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Summer |
Winter |
Monsoon |
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Fan desired (No/Slow/Fast) |
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Air-conditioning (Must have/ can tolerate/ cannot tolerate) |
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Covering during sleep (Thin/thick
blanket) |
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Drinks (Hot/cold) preferred |
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Bathing with
hot/warm/cold water |
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Sun exposure (No effect/ aggravates/ feels better) |
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Covering of feet (Yes/No) |
l) SLEEP: How
many hours do you sleep at night or in the day? Do you feel fresh on waking up
in the morning? Is your sleep peaceful or disturbed? Which position do you
prefer to sleep in? Eg: On the back, on the stomach, hands stretched
up, etc.
E.g.: I usually sleep
for 6 hours at night and wake up refreshed in the morning. Sleep is
peaceful. I sleep on the sides and back.
m) DREAMS: What
type of dreams do you usually get right from childhood? Do you remember them
on waking or not? Any recurrent dream? Any persons (alive or dead) seen in your
dream often?
E.g.: Dreams of
being attacked, dreams of snakes dreams of trying to catch a train or bus but
failing to do so, etc.
n) FEARS: Do you have any strong and persistent fears? Are you scared of any animals,
insects, darkness, height, water, robbers, persons, etc. (mention of childhood
fears too)?
E.g.: Fear of
dogs, dark, being alone, heights, crowded places, etc.
(For intensity, use
grading from 1 to 3 where 1 stands for minimum and 3 for maximum intensity.)
MIND
It is now universally acknowledged that your mind has a tremendous influence on your body. Forgiving proper treatment, it is absolutely necessary for us to understand your emotional and intellectual nature; we can thus treat you as a whole. In order to understand you, we will be asking certain questions, answer them freely, carefully, and completely. This information will help us much in giving you the correct remedy. Also, such a remedy will help improve your mental makeup.
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Are you anxious? About which matter? |
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Are you fearful of anything such as animals,
people, being alone, darkness, disease, robbers, sudden noises, thunder, about
future, high place, etc. |
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Are you doubtful or suspicious? Of what? |
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What are you jealous about? |
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In which matter are you impatient? Hurried? |
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How long do you remember hurts caused to you by
others? |
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How much revengeful are you? |
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What are you proud of? Does your pride get easily
hurt? |
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Depress, Brooding, etc? |
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Do you ever become suicidal? When? |
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Any unwanted thoughts any time? What are they? |
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Have you any imaginary sensations or fears? |
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Do you hear voices or that you are called or anything else in this like keeps on occurring in your mind? |
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How is your memory? |
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Do you weep easily? What makes you weep? |
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How do you feel if someone offers sympathy and
consolation? |
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Are you easily irritated? |
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What makes you angry? |
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Do you like company? Or like to remain alone? |
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How seriously are you affected by disorder and
uncleanliness in your surrounding? |
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Are you worried or unhappy over? Any personal,
domestic, economic, social, or any other condition? If so describe in detail. |
CLINICAL HISTORY:
BLOOD PRESSURE:
PULSE:
HEART SOUND:
CHEST:
TEMPERATURE:
WEIGHT:
TONGUE/ TONGUE
PICTURE FOR ONLINE CONSULTATION:
THIRST:
ANAEMIA/JAUNDICE/CYANOSIS/OEDEMA
FOR FEMALES ONLY
a) MENSTRUAL
HISTORY:
At what age did you
have your first menstrual period?
Are your cycles
regular or irregular?
How many days does
your period lasts on average?
Is the bleeding
heavy or scanty?
What is the color
of discharge? E.g.: bright red, dark red, blackish, or pale?
Are the stains
difficult to wash off?
Any problems you
face before, during, or after your periods? E.g. Backache, headache, excessive
irritability, and mood swings, etc.
Do you have any
white discharge (leucorrhoea) before, during, or after your periods?
What was the date
of the first day of your last period? (LMP)
b)GYNECOLOGICAL
HISTORY
Any discharges
before, after, or in between menses? Describe the nature, color, odour,
consistency, etc.
Methods of
contraception used if any
Any existing or
past gynecological condition?
c) OBSTETRIC
HISTORY
Number of
pregnancies
Living children
Abortions (If Any)
Miscarriages
Full-term /
Premature deliveries
Normal /Caesarean
Sickness during
pregnancy: E.g.: Excessive vomiting, swelling of feet, varicose veins, etc.
Any medical condition during pregnancy: E.g.: Anaemia, diabetes, blood pressure, infections
etc.
Complications
during pregnancy or delivery: Placenta Previa, obstructed labor, etc.
Medicines are taken during pregnancy if any: Antibiotics, allergy medicines, fever, etc.
11. PERSONALITY: How would you describe yourself as a
person? Your emotional aspect. How do you feel and react in various life
situations in your daily life? E.g.: You can describe your anger. What
are the things that make you angry? How do you express your anger? Similarly, anxiety, sadness, happiness, love, hatred, fears, disappointments,
frustration, suspicion, etc. Please describe your nature, behavior,
relationships, etc. (Envy, jealousy, suspicion)
Try to portray a
picture of your personality without judging as good or bad. (Min. 300
words)
12. CHILDHOOD: How was your childhood? What are your
memories of your childhood? Describe your relations with family, friends, and
teachers at present and in the past. Important or significant events during
childhood that you recollect now? (Min. 200 words)
13. SIGNIFICANT
LIFE EXPERIENCES/EVENTS(Eg: Discords,
Humiliation; Fights; Deaths; Separations; Divorce; Monetary Loss in business;
loss of job, etc.) Describe events that had a major impact on your life.
Express how you felt then and now about these events.
14. Please note that you may have some
symptoms/complaints that may seem unrelated to your main problem/s. From a
homeopath's perspective, each symptom is important, however trivial or
obsrelief it may seem. Each disrupting symptom – physical, emotional, or mental
– could be important for selecting your remedy and therefore should be
mentioned to us.
E.g.: A person
coming for treatment of his skin allergy may have dreams of snakes, which on
the face of it looks unrelated. However, it may be an important clue for
treating skin allergies.
Describe unusually
symptoms like
a) Playing with knives.
b) Laughing at serious matters.
c) Terrified of dogs. If I see a dog, I cross
the road.
d) I wash all the bed sheets immediately after
the guests who slept on them leave.
e) I feel there is a hole in my brain.
f) My body feels double.
15. DEVELOPMENTAL MILESTONES (Can take help of
parents or grandparents)
Birth weight:
When did you start
walking?
When did you start
talking (first word)?
When did your first
tooth erupt?
Were the milestones
delayed?
Any other problems or illnesses during early developmental years? E.g.: Illness such as jaundice, TB, chickenpox, measles, etc.
ENCLOSURES
a) Medical reports or Consultations:
b) Investigation reports
c) Investigation plates: E.g.: X-ray, USG, CT
scan, etc
[Attach
photographs, reports (scanned copies), videos with file name format in which
submitted. Tabulate comparative submissions.]
DISCLAIMERS:
Treatment given is based solely on the information provided by the
patient. It is entirely the patient’s responsibility to provide accurate and
complete information.
All outstation patients, in case of emergency, must immediately seek
medical help and visit the local hospital.
Medicines sent outstation may take some time to reach depending on the
delivery services available.
DATE AND PLACE:
SIGNATURE OF
PATIENT / OR GUARDIAN:
FOR PAYMENT, PLEASE CONTACT THROUGH EMAIL
WHEN IT WILL UPLOAD FOR TAKING TREATMENT…
HOW TO
PROCEED? PLEASE SEE ONLINE
CONSULTATION IN WEBSITE
Verified By: DR ANUTOSH CHAKRABORTY
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