Treatment Questionnaire

30 Days Homeopathy Treatment Plan

Including consultations and medicines

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The Treatment Process

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Name

Gender

Male Female

Age

Height

Weight

City

Phone

Occupation

Your General Nature

Details about your present Disease/ailments in order of appearence with duration

If you have already seen a doctor what diagnosis did they give you?

What investigations, tests have you undergone? Please mention the reports and brief treatment history

Is there anything else that might be helpful or relevant to your problem? including allergies, illnesses that run in the family and a little bit about your lifestyle.

Past History
(Any significant disease like : Hospitalisation if any : Any problem of Diabetes/ Hypertension/ Arthritis/ Asthma etc.Any treatment taken earlier , its duration and its outcome.)

Physical Generals

Which weather you prefer most:

Appetite

Thirst

Liking for specific taste/food:

Urine:

Stool:

Perspiration:

Sleep pattern, Position during sleep:

Speed(Walking, eating, Working):

Sensitivity:
(To noise/ light/ sunlight/ high neck, ties/narrow places/ closed rooms/ traveling in vehicles/ by air/ perfumes/ dust/ others)

Females

Gynae and Obs history:

Age of menarche/ menopause:

History of abortions or miscarriage:

Family history

Name the diseases which your father/ mother/ siblings might have suffered

Anything else you would like to share with the doctor?

Cigarettes/week:

Alcohol units/week:

Allergies

Eczema:

Hay fever:

Sinusitis,Cold:

Allergic bronchitis:

Asthma:

Urticaria:

Arthritis

Gout:

Osteo-arthritis:

Rheumatoid arthritis:

Cancer / Malignancy:

Diabetes Mellitus:

Hypertension:

Coronary Artery Disease, Angina etc.

Tuberculosis:

Gonorrhoea / Syphilis or STD:

Psychiatric & Mental Disorders:

Schizophrenia:

Anxiety Neurosis / Depression:

Any other sickness not mentioned above?

PERSONAL HISTORY

Allergies:
(If any)

Tendencies:
( like Cold, Viral, Infections, Boils etc.) or any other

Are you Vegetarian or Non Vegetarian?

Smoking:
(If Yes - How many and since when?)

Drinking Alcohol:
(If Yes - quantity, duration and frequency)?

Any Other Addictions?:
(Tobacco/ Paan Masala/ Drugs etc?)

Temperature:
(Normal/Subnormal/ Raised) ?

Physical Activities?:
(Walking/Jogging/Swimming/Sports/Playing)

SLEEP:
(Whether restless/ disturbed/ sound/ position during sleep ?)

DREAMS:
( Whether regular / occasional and type of Dreams)

APETITE:

THIRST:

TONGUE:
(Whether Clean /Coated /White /Thick/ Ulcerated/ Mapped. Any Spots, Any Smell ?)

DESIRE or CRAVINGS of any food, unusal things etc:

AVERSION or DISLIKE to any:

URINE:
(frequency, character, color and associated complaints)

STOOL:
(frequency, character, color and associated complaints)

SWEATING:
(Quantity and any particular location)

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Treatment Questionnaire

30 Days Homeopathy Treatment Plan

The Treatment Process

Select a Health Plan

Sign Up

Make the Payment

Fill the Questionnaire

Video Call with Specialist

Receive Medicine & Start Treatment

Fill the Questionnaire

Select a
Health Plan

Make the
Payment

Fill the
Questionnaire

Video Call with
Specialist

Receive Medicine &
Start Treatment