Adult Patient Case Form

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Name *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Residence Number

Mobile Number

Email *

Age

Sex

D.O.B//

Diet

Marital Status

Occupation (Nature of Work)

Education

Referred to us by

Disease suffered from

Approximate Age

Duration

Disease suffered from (copy)

Approximate Age (copy)

Duration (copy)

Disease suffered from (copy) (copy)

Approximate Age (copy) (copy)

Duration (copy) (copy)

Disease suffered from (copy) (copy) (copy)

Approximate Age (copy) (copy) (copy)

Duration (copy) (copy) (copy)

Disease suffered from (copy) (copy) (copy) (copy)

Approximate Age (copy) (copy) (copy) (copy)

Duration (copy) (copy) (copy) (copy)

Whether you completely recovered

Medicines & treatment taken

Any other particulars

Whether you completely recovered (copy)

Medicines & treatment taken (copy)

Any other particulars (copy)

Whether you completely recovered (copy) (copy)

Medicines & treatment taken (copy) (copy)

Any other particulars (copy) (copy)

Whether you completely recovered (copy) (copy) (copy)

Medicines & treatment taken (copy) (copy) (copy)

Any other particulars (copy) (copy) (copy)

Whether you completely recovered (copy) (copy) (copy) (copy)

Medicines & treatment taken (copy) (copy) (copy) (copy)

Any other particulars (copy) (copy) (copy) (copy)

Family History

Personal History

Did your mother have any problem during pregnancy?

Did she take any drugs during pregnancy? What were they?

Was there any difficulty about your birth? Give Details.

At What Age Did You Start

Teething

Sitting

Standing

Walking

Speaking

Urine control / bed-wetting etc.

Eating indigestibles like chalk, lime, earth, state-pencil, etc.

Any other problem about your growth & development?

Vaccination & Inocculations

Was there any reaction or particular trouble after any of above vaccination or inocculations?

Give Details

Number of children living and dead

If dead, state causes

Any abortions, miscarriages or still births?

MAIN COMPLAINTS AND OTHER ASSOCIATED TROUBLES : (AND DETAILED HISTORY OF THE PRESENT ILLNESS, THE ONSET AND COURSE WITH DATES)

Appetite & Thirst

How is your appetite?

When are you most hungry?

What happens if you have to remain hungry for long?

How fast do you eat?

How much thirst do you have?

Do you feel any change in your taste and feeling in your mouth?

Bitter Food

Salt Extra

Sweet Food

Sour Food

Bread

Butter

Fats

Milk

Coffee

Mud / Chalk

Spicy Food

Cabbage

Onions

Warm Food / Drink

Cold Food / Drink

Fruits

Stool

Do you have any problem regarding your stools?

Do you have to strain for stool? Even if soft?

When and how many times a day you pass stools?

Do you have any problem about bowel movements?

Do you have belching or passing gas? Describe its character

Urination & Urine

Any problem about urine?

Any strong smell? Like what?

Any difficulty about the flow? Slow to start, interrupted, feeble, dribbling etc.?

Any involuntarily urination? When?

Do you have any trouble before, during and after passing urine? After passing urine, sometimes 2-3 dropping of urine most of the time but not always?

Sweat / Perspiration - Fever - Chill

How much do you sweat?

Where and on what part do you sweat most?

Do you perspire on the palms or soles?

What is the smell like? E.g. foul, pungent, sour, urinous

Is the sweat warm, cold, clammy, sticky, musty, greasy, stiffens the linen etc.?

Sleep

Describe your posture in sleep, on the back, side, abdomen etc.

Describe if anything else is unusual about your sleep

Sweat / Perspiration - Fever - Chill

How is your sexual desire?

How do you feel after sexual intercourse?

Do you suffer from any sexual disturbance?

Any particular feeling or symptoms appear before, during or after sexual intercourse?

Any habit like (masturbation etc.) in past as well as present? How often?

Any homosexual inclination?

Any difficulty in erection?

What is the method you use for family planning (contraception)?

Did you suffer from any sexually transmitted disease? Syphilis? Gonorrhoea? Herpes? HIV?

Weak erection? Failing erection? Describe.

Any other trouble in sex? Describe in details.

Mind
It is now universally acknowledged that your mind has tremendous influence on your body. For giving 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 make up. Answer freely. Answer frankly. Answer completely.

Are you anxious? About which matters?

Are you doubtful or suspicious? Of what?

Are you fearful of anything such as animals, people, being alone, darkness, death, disease, robbers, sudden noises, thunder, of the future, of something unknown, high places, etc.?

What are you jealous about? Of whom? From what symptoms do you suffer when jealousy?

In which matter are you impatient? Hurried?

How much revengeful are you?

How long do you remember hurts caused to you by others?

Do you ever become suicidal? When? If so in what manner do you contemplate to end your life? Even then, are you afraid of dying?

When are you cheerful?

Are you sexual-minded?

Any unwanted thoughts any time? What are they?

Have you any imaginary sensations or fears?

How is your memory? For what is it poor? e.g. names, places, faces, what you have read, etc.

Do you hear voices, or that you are called, or anything else in this line keeps on occurring in your mind unduly?

Do you weep easily? What makes you weep? How do you feel after weeping?

How do you feel if someone offers sympathy and consolation?

Are you easily irritated? What makes you angry?

What bodily symptoms do you develop when angry? e.g. trembling, sweating etc.

Do you like company? Or like to remain alone?

How seriously are you affected by disorder and uncleanliness in your surrounding?

What are the greatest griefs that you have gone through in your life?

What are the greatest joys that you have had in life?

What activities you deeply like? Are there any matters which you deeply dislike?

In your opinion, which aspects of your mind and moods are not agreeable to you. Inspite of your awareness and maturity, are you unable to change these aspects?

Give a clear cut picture of your situation in life and your relationship with each of your family members, friends and associates in work.

How the future looks to you?

When you are free, what thoughts come to your mind Are you worried or unhappy over any personal, domestic, economical, social or any other condition? If so describe in detail

If asked for 3 desires or wishes in life, what will you ask for?

By whom?

For what?

If any other, specify here

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