Online Consultation / Treatment Form

For those who want to avail effective Professional Homoeopathic consultation / treatment, kindly fill the following questionnaire. All the information that you will be providing here remains confidential as said in our Privacy Policy.

Note: Kindly make sure that the email-id is functional. Many times it is found that the replied mail is bounced back. Please do not use this form to submit progress report. Reply to the email address at which you received your treatment plan. (*=Mandatory)

Name	*	E-mail	*
Address		Telephone No.
Date of Birth	*	Sex	*
Occupation	*	Blood Group	*
Marital Status	*	Children

Personal History

Childhood Illness: (Check all that apply)

Measles

Mumps

Chicken Pox

Rheumatic Fever

Rubella

Immunizations: (Check all that apply)

Tetanus

Hepatitis

BCG

Chicken Pox

MMR

Poilio

Have You Ever Had Following: (Check all that apply)

Arthritis	Cancer	Diabetes	Depression	Dizziness	Epilepsy
Hepatitis/jaundice	Herpes	High Blood Pressure	Eczema	Sore throat Frequent	Venereal Disease

Medical History

(Check all that apply)

	Asthma		Chronic Bronchitis
	Allergy (sensitive) to any or various substances including food & pollens		Tuberculosis (TB)
	Sinusitis		Warts
	Glandular swellings (thyroid / tubercular / testicles)		Migraine/Headaches
	Alcohol or any other addiction		Back or Neck Pain, Stiffness, Soreness

Family History

(Check all that apply)

Blood Disease/Clots

Father

Mother

Sibling

Grand Parents

Cancer

Father

Mother

Sibling

Grand Parents

Diabetes

Father

Mother

Sibling

Grand Parents

Epilepsy

Father

Mother

Sibling

Grand Parents

Heart Disease

Father

Mother

Sibling

Grand Parents

High Blood Pressure

Father

Mother

Sibling

Grand Parents

High Cholesterol

Father

Mother

Sibling

Grand Parents

Triglycerids

Father

Mother

Sibling

Grand Parents

Mental Illness

Father

Mother

Sibling

Grand Parents

Stroke

Father

Mother

Sibling

Grand Parents

Thyroid Disease

Father

Mother

Sibling

Grand Parents

Tuberculosis

Father

Mother

Sibling

Grand Parents

Any other Family history:

Specify Your Main Complaints/Symptoms

Please don't use Medical diagnosis/present treatment here; it is advisable that you use your own words and not medical terms. Describe if any of the symptoms are made worse or better under any circumstances or the problem appeared after any particular event of your life.

Mental Symptoms

(Check all that apply)

Suspicious	Irritable	Feel Stressed/Tired	Laughing during talking
More worried about others	Talkative	Quiet	Wanted to do things in hurry?

Do you suffering from any anticipatory feelings? (Specify)

How would you describe yourself & your character?

Type of Dreams (specify)

Sleep (specify e.g. Troubled/Sound etc.)

Emotions (specify)

Sad Events (if any)

Skin Problems (Present / Past) (Specify)

Gynecologic History

Are your periods regular? Yes No	Have you gone through menopause? YesNo
Breast Heaviness/Pain before Menses? Yes No

Obstetric History

No of Pregnancies?	No of Miscarriages?
No of Abortions?

Present Treatment

State present treatment with detailed information regarding medicines and its dose plus any herbal or vitamin supplements that you might be taking.

Diagnosis

Provide details of Diagnosis (if any). Write the Conclusion of the Clinical Reports (if any).

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