Homeopathic doctor clinic for consultation with questionnaire for treatment homeopathy.

Dr. Rohit Jain's
Online homeopathic clinic

Consultation Form

After the consultation form is filled by you, we would decide whether homeopathy can help you or not. If we feel homeopathy can give you relief, further treatment plan is discussed mutually which includes - medicines to be taken, duration involved, diet and regimen to be followed, payment modalities, etc. If you have any queries please feel free to contact us.

Fields marked with * are mandatory.


Name:*
Age:*
Birth Date:
Sex:*
Marital Status:
Occupation (Nature of Work):
Address:*
City:*
State:
Country:*
Zip/Pin code:
Telephone:	Residence
	Office
Mobile:
Email:*

Present Complaints

Kindly mention about your complaints in your own words. Please describe fully the trouble, including its origin, subsequent development and effects of treatments that were received. In this description, please be certain to cover at least the following points:

	Area of body affected and when
	Sensations and pains experienced
	Circumstances (physical & emotional that have brought on the trouble)
	Conditions that increase the trouble
	Conditions that reduce the trouble
	All other accompanying troubles
	Present Complaints

Personal History

Your Habits	How Much ?
Smoking
Alcohol
Tea
Coffee
Sleeping Pills
Laxatives/Purgatives

Milestones of Life

Teething, Trying to sit up, Walking, Talking, etc. (whether on time, delayed, early)

History of Trauma

Broken bones, Accidents, Head injuries, Dog/Insect bites, etc.

Past History

Diseases suffered	Approximate age	Duration	Whether you completely recovered	Medicines & treatment taken	Any other particulars

Family History

Any history of Cancer, Diabetes, Arthritis, Tuberculosis, Epilepsy, Skin diseases, Asthma,
CVA/Stroke, Hypertension, Kidney diseases, Liver diseases, etc.

Appetite & Thirst

How is your appetite?
How much thirst do you have?
Any change of taste in your mouth?
What are the foods or drinks you like?
What are the foods or drinks which make you worse?
Stool
Do you have any problems regarding your stools?
Do you have belching or passing of gas?
Urination & Urine
Any problems regarding urination or urine?
Sweat
How much do you sweat?
Do you perspire on the palms or soles?
Any symptom relating to sweating?
Cold / Cough
Do you catch cold easily?
Sexual Sphere
Any problems relating to sex or sexual organs

Miscellaneous

What kind of weather are you most comfortable in?
Are you particularly uncomfortable in any weather or climate?
How is your tongue � clean or coated?
What about tonsils, adenoids and polyps in nose?
What about salivation?
What about sleep?
Do you like to be in open air or do you feel more comfortable in a closed room?
Additional information if any

Additional Queries for Female Patients

Age at onset of periods (Menarche)?
Periods? (Regular/Irregular)		Yes		No
Physical symptoms preceding the onset of periods (E.g. heaviness/pain in the breasts, changes in moods, changes in appetite, changes in bowel habit, backache, pain in the legs, headaches, dreams etc.)?
Duration and interval between periods (E.g. bleeding last for 3-5 days and the interval between periods is 27 days)?
Are you using any contraceptive pills?		Yes		No
Any discharge before/during/after periods?	Before During After
Number of children and whether the deliveries were normal? Any post-delivery problems? Were the children breastfed or not? Any problems during the breastfeeding phase? Any abortions? Any complications after abortions?
Age of onset of menopause
Did the periods cease gradually or abruptly?		Gradually		Abruptly
Have you had any operations done in the pelvic area?		Yes	No
	If yes, details