Patient History

Here is a list of questionnaire, request patient to enter all relevant information regarding the illness qwery helps in accuracy in diagnosis, also pls share photos in case of any skin infection or boils illness and send it to the mail id homeophilia@gmail.com.

Particulars of Patient:

 

1.  Name

2.  Age

3.  Sex

4.  Married/Unmarried

5.  Religion

6.  Occupation

7.  Address

8.  D.O.B (Date Of Birth)

9.  Height: Tall/Medium/Short

10. Build: Thin/Normal/Obese

Present (Chief) Complaint.

Please state all the disorders patient has latterly suffered from---even if he considers any of them unimportant, or not related to his main complaint. 

Part of the body affected. 

Sensations and complaints. 

Modalities. Aggravation/Amelioration. 

Probable cause. 

A.

Please state briefly the serious complaints the patient has suffered from since childhood. 

B.

a)   Nature of complaint. 

b)  Year of occurrence. 

c)   How long did it lost. 

d)  Any recurrence thereafter. 

C. 

Any history of 

a)   Asthma, 

b)  T.B, 

c)   Cancer, 

d)  Psoriasis, 

e)   Insanity or any other disease. 

 

D.

Any disorder of senses of Taste/Smell/Hearing/Vision/Touch. 

E.

Appetite/Hunger; is it normal? 

Excessive? Deficient, Capricious (At unusual time)? (Waiting). 

F. Does he feel filled up after a few morsels of food, Abdomen bloated, Flatulence (Gas)/Heartburn /Eructation. 

G. Food items for which patient has a craving of aversions and which disagree with him. 

Food Items. Cravings. Aversion. Disagree. 

Sweets. 
Salty things. 
Sour things. 
Milk. 
Eggs. 
Meat/Fish. 
Butter. 
Spices(Condiments) 
Potatoes/Starchy food. 

Fried things. 
Drinks, Warm/Cold. 
Drinks, ice cold. 
Onion/Garlic. 
Raw vegetables. 
Juicy, refreshing things. 
Alcoholic Liquors. 

ANY OTHER. 

H. Thirst.

Please indicate the intensity of his thirst with suitable ticks. 

Thirsty (Drinks a lot in a day). 

Thirst less (Drinks comparatively little in a day): 

Quantity and frequency: Thirst for large/small quantity and at long/shorts intervals. 
Stools. Please indicate severity with plus marks: 

I. Nature of stools.

Soft, Hard, Bloody, Slimy, with urging, Must strain, No of stools. 

Normal, 
Constipated. 
Loose. 
Dysenteric. 

Piles. 

Bleeding; ----Blind; ----Protruding; -----itching----Burning, -----Fissures, ----Painful, ----Fistula. 

Aggravated by; -----------Ameliorated. 

J. Urine. 

Profuse/scanty; ----Frequent, -----Dribbling, -----Burning, -----Involuntary—Day/Night, 
Colour, odour, painful, deposits, sugar, stones (Kidney/Bladder). 
Position in which urine passes easily. 

K. Breathing. 
Any complaints: ------ Bronchitis; Asthma, Rapid, Oppressed, Rattling, Wheezing, 
Difficult Expiration/inspiration. 

Cough. 
Hollow/Harassing/Tickling/Spasmodic.Dry,loose. 

Expectoration. 
Taste, Odour, copious/little., watery, Tenacious. 

L. Sexual. 

 

Male. 

Desire: strong/weak. 
Erection. Strong/weak 
Emission. In sleep, during stool/too early. 
Coition, any complaint during, or after. 
History of venereal diseases. 

Female. 
Age at first menstruation. ------. 
Menses. 
Profuse/scanty: Too early/Too late. 
Flow. 
Red/Dark/Pitch like/Smell Fetid.Any other. 
Nature of the complaint in relation to menses. 
Before menses/During Menses/After Menses. 

Leucorrhoea.
Watery/Thick/Tenacious/Fetid smell/Acrid? Excoriating/Any other. 
Causes Itching. 
Abortion if any. 
During which month of pregnancy. 
Coition: Aversion to.Desire, Strong/Weak. 
Number of children: ----Sterility. 

M. Side of the body Affected. 

(Please name the anatomical region, also stating right or left side of the body) 
Complaints first appeared in ------Right/Left. 
Complaints then extended to-------Right/Left from. 
Complaints shift from place to another. 

Cold or Hot (Burning) Sensation. 
Cold/Hot (Burning in:Vertex/Eyes/ears/Face/Stomach/Abdomen/Back/Palm/Soles.Any other. 

N. Sweat. 

 

If excessive. 
Where/When/Odor of sweat/Does it stain clothes/Color of the stain. 
Very little sweat (Dry skin) 
Partial Sweat on; Head/Face/Soles or others. 

Skin, Glands/Bones. 
Nature of disease.Where/Dry/Oozing/Itching/Moist/Watery/Viscid/Bloody/Pus/Burning.

O. Sleep. 

Normal/Sound/Disturbed/Difficult/Too sleepy/Sleeplessness/Unreflecting. 

P. Position in sleep. 

Lies on back/on right/left./lies on abdomen/Head rose. 
Dreams.Pleasent/Unpleasent/Nightmare/Snoring. 
Modalities. 
At which time the complaint is aggravated/Ameliorated. 
Under what circumstances the complaint is aggravated/Ameliorated. 
In what season the complaint the complaint is aggravated/amelioration. 

Q. Mental attitude. 

Sensations. 
Ball or plug/burning/heat/benumbing/bruished/bursting/splitting/chilly/cramps/constricting/contracting/dizziness/vertigo/emptiness/fullness/itching internally/tingling/lethargy/itching/scratching/hammering/neuralgic/hammering/numbness/restlessness/scraping/sinking feeling/jerking/twitching/stiffness/rigidity/stinging/sprained/dislocated/throbbing/pulsating/trembling/quivering/tightness/tension./any other. 

R. Any other complaint. Please write in detail.