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Thursday, November 29, 2012

SAMPLE HOMEOPATHIC CASE RECORD


Homoeopathic treatment is determined by looking at the whole patient as a unique individual rather than categorizing his or her illness based on symptoms that are similar to those of other patients. According to homoeopathic thought, the body's symptoms of illness are an expression of the body trying to heal itself and should not be suppressed. This individual expression of symptoms is of utmost importance in determining homoeopathic prescriptions, since the remedy must perfectly match the symptoms.
The first step in homoeopathic treatment is obtaining information about the disease, or taking the case. One has to be observant and objective. Words used by the patient are generally better indicators of the symptoms, so it is better not to interpret, but to note down the same words.

1.       Name
2.       Age
3.       Sex
4.       Marital status
5.       Postal address
6.       Email
7.       Chief complaints
a.       What is your suffering/ difficulty at present
b.      How long are you suffering? Is there any particular cause for the beginning of your complaint?
c.       When do you feel better/ what do you do to get relief from your complaint?
d.      When does your condition get worse?
e.      Do you have any associated complaint with your presenting complaint?
8.       If the case is already diagnosed then diagnosis of the case? Who diagnosed the case?
9.       If investigation done reports of investigation (with date).
10.   Under any medication, if yes specify treatment and medicine name.
11.   Present History (Whether patient is suffering from any diseases like Arthritis, blood pressure, Diabetes, HIV, Tuberculosis or Cancer) specify since when?
12.   Past History (Any diseases which occurred in the past Tuberculosis, hepatitis, typhoid, etc any others specify when. If patient has undergone any surgical intervention for what and when.)?
13.   Family History (Family history of any disease)?
a.       Whether father and mother alive?
b.      If yes do they suffer from illness, If no how did they die?
c.       How many brothers and sisters do you have, do they have any illness?
d.      Are there any hereditary diseases in your family?
14.   Craving for food or drinks specify.
15.   Aversion to any food items?
16.   Intolerance for any food item?
17.   Aggravation from any food item?
18.   Thirst.
19.   About your perspiration (Is it decreased, increased or no perspiration or any color or odor, any staining, etc)
20.   Urine (Any color change or any difficulty in urination)
21.   Bowel motion (No of times/ day or any other ailment regarding bowel motion)
22.   If any climate you prefer specify
23.   Any addiction to alcohol, smocking, chewing, drugs, etc
24.   Menstrual flow (How many days, presence of clot or any abnormal discharge)
25.   About fertility, if any problems
a.       How many times did you become pregnant?
b.      Did you have any abortions? (Give details)
c.       Did you suffer from any disease during pregnancy?
d.      Was your pregnancy normal of cesarean session? If cesarean what was the reason?
26.   Sexual relations and problem of sex.
a.       Do you have any difficulty in sex?
b.      Do you have any premarital or extra marital relation?
27.   Any peculiarities about your dreams
28.   If your complaint occur in any one side of the body?
29.   Do you feel warmer or colder than others? If yes please explain with situations.
a.       Response to fanning, bathing, climate, open air, etc?
30.   Any peculiarities about your sleep?
31.   Mental features including attitude, fear, anxieties, other thoughts etc.
a.       Any depression, disappointment or sadness which is deep rooted in the mind for very long time after which the presenting complaints arise?
b.      Do you prefer company/ prefer sit alone and be to yourself?
c.       How close you are to your family and friends, do you like being with them?
d.      How do you see your future? (Optimistic / pessimistic, any suicidal disposition/tendency/thoughts)
e.      How sensitive are you? Do you weep immediately if anyone hurts you or get angry/ irritated?
f.        How do you react when person insults you?
g.       Reaction to silly matters? (Easily angered / Easily weeping, etc.)
h.      Do you have jealousy if anyone gets the thing/achieve anything which you wanted/ how do you feel?
i.        Do you compel everyone to listen to you/ believe that you are right? Do you feel irritated if anyone doesn’t listen to your words/ ideas?
j.        How do you respond to injustice?
k.       Are you courageous? Do you want people always with you when you go out?
l.        Do you have any fear to public performance (stage fright)/ crowded places (festivals, parties/ ceremonies)/ higher altitude/ open places/ narrow places/ loneliness/ darkness/ diseases/ dirt/ infection/ strangers/ death/ opposite sex/ thunderstorm/ lightning/ evil spirits/ animals/ robbers/ etc.,) explain?
m.    Any mental confusion at work/ doing any calculation?
n.      How is your memory?
o.      Concentration in work?
p.      Do you make mistakes while writing, reading, speaking / while doing calculation?
q.      Any anxiety about your health or others health?
r.        Do you like travelling, music?
s.       How do you react when a person talks against your ideas/ views?
t.        What do you do in your spare time?

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