NEW RESEARCH FORM

NEW RESEARCH FORM

NEW RESEARCH FORM: HOMEOPATHIC LINE OF TREATMENT

Please take your time and fill out this form at length. This form is of crucial importance in researching the correct selection of homeopathic remedies/ line of treatment.

DATE

NAME

ADDRESS

CITY/ STATE/ PIN

PHONE

MOBILE

E-MAIL

AGE

SEX

DATE OF BIRTH

PLACE OF BIRTH

PRESENT HEIGHT Ft & ins / cms

PRESENT WEIGHT Pounds/ Kg

MARITAL STATUS

CHILDREN

BUSINESS / WORK

DESCRIBE YOURSELF IN 50 TO 100 WORDS.

PRESENT COMPLAINTS. Please list each complaint and describe in detail (memory, vision, taste, smell, sleep, dreams, digestion, elimination, hair, skin, circulation, heart, lungs, organs, joints, muscles, glands, thyroid, bones, neck, spine etc)

10.

ONSET, ORIGIN OR CAUSE When did complaints begin? Were there any event (s) responsible eg injury, accident, dental work, operation, grief or shock?

PAST HISTORY (PREVIOUS DISEASES AND TREATMENT) List details about your past medical history, including dental work, operations and injuries.

SUPPLEMENTS/MEDICINES List dosage and frequency of all supplements/ medicines.( BP, diabetes, thyroid, anti depressants, steroids, hormones, vitamins, supplements etc )

FAMILY HISTORY Relatives (mention relationship) suffering/suffered from : ALLERGIES

Eczema ……..Y/ N

Skin allergy……YES / NO

Hay fever ……YES / NO

Sinusitis or colds ……YES / NO

Allergic bronchitis ……YES / NO

Asthma ……YES / NO

Urticaria ……YES / NO

ARTHRITIS

Gout ……YES / NO

Osteoarthritis ……YES / NO

Rheumatoid arthritis ……YES / NO

OTHER MEDICAL CONDITIONS

Cancer/Malignancy ……YES / NO

Diabetes Mellitus ……YES / NO

Hypertension ……YES / NO

Coronary Heart Disease. ……YES / NO

Tuberculosis (Pleurisy) ……YES / NO

Gonorrhea/Syphilis or STD ……YES / NO

Psychiatric A Mental Disorders ……YES / NO

Schizophrenia ……YES / NO

Anxiety Neurosis Depression ……YES / NO

Hyperthyroidism/Hypothyroidism ……YES / NO

Any other sickness not mentioned above.

PERSONAL HISTORY: Kindly elaborate and mention habits like drugs, smoking, tobacco, alcohol etc.

APPETITE :

Grade as per preference +1, +2, +3/ dislike or aversion -1, -2, -3

Sweets ……… What do you like?

Salt and salty food (any extra salt) …….

Sour things like pickles/ vinegar ………

Seasoned and spicy …………

Milk ………………..

Eggs …………

Fried foods and fat ………..

Foods that you like ……….

Foods that you dislike ……..

Complaints after eating.

Fullness of abdomen ……YES / NO

Gas formation ……YES / NO

Diarrhea ……YES / NO

Can you remain hungry for long periods? ……YES / NO

Do some foods cause any discomfort e.g. acidity. headache, flatulence etc. ……YES / NO

Details of foods/timings?

Do you feel bloated, full and heavy after eating ……YES / NO

THIRST:

State or grade +1, +2, +3 / -1, -2, -3

How much water do you take at one time?

How many times per day?

Would you prefer warm/ hot in the height of summer? +1 +2 +3 / -1 -2 -3

Would you prefer cold/chilled water/drinks in the height of winter? +1 +2 +3 / -1 -2 -3

Iced cold drinks/ water +1 +2 +3 / -1 -2 -3

Cold drinks +1 +2 +3 / -1 -2 -3

Warm drinks +1 +2 +3 / -1 -2 -3

Very hot drinks +1 +2 +3 / -1 -2 -3

GENERALITIES State how you are affected by or how you react to the following :

1. Cold in general: cold air, drafts, cold winds etc.

2. Warmth in general: warmth of bed or of room, external warmth etc.

3. Weather: dry, cold, wet weather, rains, cloudy etc.

4. Thunder storms?

5. Open fresh air?

6. Sunlight and exposure to the sun?

7. Near the sea? Near the mountains?

8. Eating and drinking (before, during or after) any symptoms?

9. Fasting?

10. Any particular item of food /drinks which adversely affect you (or make you sick) ?

11. Closed, crowded places (e.g.: elevators etc.)

12. Exertion or physical strain, mental strain ?

13. Lack of sleep ?

14. In what part of 24 hour day ...

Do you feel the best? Is there a specific time?

Do you feel the worst? Is there a specific time?

15. Do your troubles tend to occur or become worse periodically ? (e.g.; daily or

alternate days, every week, yearly, during new or full moon etc.)

STOOL/BOWEL MOVEMENTS

Do you regularly have a satisfactory bowel evacuations?

How many times do you move the bowels? When?

Consistency

Odor

Color of stool

Any straining for stools, even though they might not be hard or constipated?

Any urgency for stools (e.g. : do you have to run for bathroom first thing on waking up,

in the morning or immediately after eating)

Any pain, burning. bleeding with stools? Piles/Fissure/Fistula?

Do you have flatus (wind) along with stools and is it noisy?

URINE

Frequency, day and night; any smell (odor) in the urine?

Any difficulty in passage of urine?

Any difficulty in retaining urine?

Any associated complaints with urination?

SEXUAL SPHERE FOR MEN

Any sexual disturbance?

Excessive desire or aversion to sex?

Disability or performance, premature ejaculation etc.

Night emissions

Any H/O sexual abuse, excessive masturbation etc.?

Any problem or complaints after intercourse?

SEXUAL SPHERE FOR WOMEN

Age of appearance of first period (Menarche)

Pregnancies ……..Children ………… Abortions ………..

MENSES

Periods : Regular ………. or Irregular ………….?

(heavy …………, scanty…….., clotted ………., color ……… odorous …………..)

Complaints associated with, before or after menses (e.g. headaches, irritability,

premenstrual depression, diarrhea or constipation)

Any heaviness or pain in breasts before menses?

Any nodules in the breast, any other premenstrual symptoms?

Do you experience any sexual disturbances?

Desire/aversion to coitus?

Any leukorrheal (white discharge)? Itching, burning or discomfort?

Any sense of weight or bearing down at time of menses?

Have you ever taken birth control pills/ Give details.

Regular use of an IUD? Yes/No

MENOPAUSE

Age at ……….

Any associated complaints at time of menopause, e.g.: Hot flashes, palpitation, anxiety,

depression etc.?

PERSPIRATION (SWEAT)

1. Do you perspire a lot?

2. Any particular part of the body, where you perspire more?

3. Any strong, offensive odor (e.g. sour etc.) associated with the sweat?

4. Does the perspiration stain the clothes?

SLEEP

1. Do you sleep well?

2. Any particular posture in which you sleep, lying on the sides, back or on your abdomen etc.?

3. Do you feel refreshed after sleep?

4. Do you dream while sleeping?

5. Any particular dream that is recalled and often repeated (e.g. : frightening dreams, falling from a height, being pursued by someone, or dead people etc.)

6. Do any of your complaints get worse or better before, during, or after sleep?

SKIN

1.Any skin problem that you have had earlier? (e.g.: allergies, eczema, fungal infections, pigmentation etc.)

2. Any itching or discoloration associated with it?

3. Any factors noticed which worsen the skin problem?

4. Any treatment taken for it?

5. Any complaint or abnormality of nails or the surrounding skin ?

6. Any complaint of hair falling out, early graying, dandruff, thinning, etc.?

7. Any warts, moles, birth marks on the body?

8. Does skin heal normally or takes very long to heal? Any tendency to form excessive scar tissue ? (Keloids - overgrowth of scar tissue at the site of a healed skin injury)? Any tendency for wounds to suppurate (form pus easily)?

9. Warts removed surgically or chemically. Describe if so.

10. After vaccination (s) any occurrence of warts or skin problems, dryness, falling hair etc. Describe if so.

THE MIND

Have you noticed any marked changes in your mental state? If so describe in detail.

Have you become or are you

1 . Anxious/afraid of anything e.g.: being alone, animals, darkness, disease, thieves, robbers, sudden noises etc. ?

2. Suspicious, doubting ?

3. Impatient or hurried, hasty?

4. Offended easily (can't take any criticism) ?

5. Are you overly critical of others, always finding fault?

6. Irritable, quarrelsome, violent etc. ?

7. Depressed easily, sad or gloomy?

8. Timid/ shy, bashful ?

9. Jealous or suspicious?

10. Anxious, restless, nervous or excitable?

11. Do you feel very anxious and apprehensive before examination, before

stressful situations, public engagements etc. ?

12. Are you silent, quiet, reserved or talkative? Make friends easily?

13. Are you very affectionate? Do you demand love and warmth from others?

14. Do you cry easily? What makes you cry (grief of others, music, kind words of affection etc.)

15. If someone consoles you when you are upset, does it help or does sympathizing with you makes matters worse?

16. Do you vent your worries, emotions etc., bottle them up inside you or brood over them?

17. How do you stand and react to contradiction?

18. Any imaginary fears or feelings? (e.g.: that someone might want to harm or hurt you or that people are against you)

19. How is your memory, power of concentration and mental ability?

20. Do you regret anything in life or resent certain people; if so who and for what reasons?

21. Do you feel humiliated or hurt easily? Would this give rise to any physical complaints?

22. Are you over conscientious about details., cleanliness, tidiness, punctuality, etc.?

Are you a perfectionist by nature, being meticulous, fastidious and even finicky?

23. What is the greatest grief that you have felt in life? Also what are the greatest joys in life you have experienced?

24. Can you mentally relax easily; for instance, can you switch your mind off work, problems, children, etc.? Do you enjoy vacations? And can you totally relax when on a holiday or do thoughts of work or what is happening at home keeps bothering you, etc.?

25. At work or with colleagues, subordinates, or your boss or seniors: How do you equate

with them? Would reprimand or scolding from them upset you tremendously? If so how?

26. How does music affect you? What type of music do you listen to?

THE EYES

1. Is your eyesight weak? Do you wear spectacles / contact lens? Give full details.

2. Write out all eye medications that you have taken in the past /are taking presently with reason for taking?

3. Have you noticed any marked changes in your eyesight? If so describe in detail.

4. Have you suffered from frequent eye infections? If so describe in detail.

5. Do you see any flashes of light or dark spots ? If so describe in detail.

THE EARS

1. Write out all ear medications that you have taken in the past /are taking presently with reason for taking?

2. Have you had ear infections/hearing loss in the past? If so describe in detail.

3. Are you suffering from ear infections/hearing loss at present? If so describe in detail.

THE TEETH

1. Describe all dental work done on your teeth with approximate dates?

2. Have you noticed any marked changes in your health after a dental filling? If so describe in detail, such effects after the most recent dental work and earlier dental work done.

VACCINATIONS TAKEN IN CHILDHOOD

VACCINATIONS TAKEN IN LAST 5 YEARS

LEVEL OF USE OF TINNED, PRESERVED, ARTIFICIAL FOODS

LEVEL OF USE OF FRESH FOODS

DETAILS OF SHUNTS, INSERTS, ARTIFICIAL LIMBS ETC WITH DATES

USE OF SPLENDA, ASPARTAME, DIET COKE, PEPSI ETC AND QTY USED

DRUGS/MEDICATION TAKEN IN PAST

NAME FREQUENCY DOSAGE PURPOSE REMARKS

DRUGS/MEDICATION BEING TAKEN PRESENTLY

NAME FREQUENCY DOSAGE PURPOSE REMARKS

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New Version 1.1d 14-7-2006