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Patient Case History

Case History

Case taking is the process of collecting all the facts about the patient, using various tools like observation, perception, history-taking – given by the patient/attendant, clinical examination etc. in order to find a remedy for the patient – using our knowledge of Homeopathic Materia Medica, Organon of Medicine, and Reparatory.

Confidencial Case Record



NAME :-

AGE/SEX :-

DATE OD BIRTH (Age) :-

ADDRESS :-

RELISION :-

STATUS :-

Married/Widow/Divorce/Single :-

VEG/NON-VEG :-

OCCUPATION :-

EDUCATION :-

CHIEF COMPLAINTS &OTHR ASSOCIATED TROUBLES :-
   LOCATION
  ( Head, nose, legs etc)
   SENSATION
  (Feeling of pain,types)
   MODALITIES
  ( Ailments that increase or feel better)
   CONCOMITANT
  (Associated symptoms)


PAST HISTORY :-

Diseases that you had suffered in the past since birth/ Vaccination/surgeries/ allergy/ treatments/ regimen.


FAMILY HISTORY :-

PATERNAL
MATERNAL :-
Wright the diseases that they are having/suffering or death from the same.Father/Grand father/mother/Uncle/ Aunty etc.


PATIET AS A PERSON :-

PAPHYSICAL CHARACTERISTICS :-

1) DIETS & DAILY ROUTINE :-

2) DIGETION :-
D :- For Desires + normal, ++, medium, +++ intense.
A :- for Aversion – normal, -- medium, --- total Aversion


   APPETITE: Less/increase
   THIRST: (Quantity, interval)
   DESIRE – AVERSION & EFFECTS
   ALCOHOL:    FRUITS:    PICKLES:
   SPICY:    COLD (FOOD/DRINKS):
   ICE CREAM :    POTATO:
   SUGER:    EGGS:
   INDIGESTIBLE THINGS:    PUNGENT:
   SWEETS:    FERNACEOUS:
   MEAT:    SALTY THINGS:
   TEA/COFFEE2    FISH:
   MILK (COLD/ HOT):    SOUR:
   TOBACCO:
3) ELIMINATION :-
URINE: types, Color, frequency,smelling, control
STOOL: Same above
PERPIRATION: Color of cloth, area, smell, intensity

4) MENTRUAL FUNCTIONS :-
URINE: types, Color, frequency,smelling, control
STOOL: Same above
PERPIRATION: Color of cloth, area, smell, intensity

  DAY: From How many days   DAY: Last long   Regular MenstrualPeriod /Irregular M P
  AMENORROEA   MENARCHE   METRORRAGIA
  DYSMENORRHOEA   MENOPAUSE   OLIGOURRHOEA
  LEUCORREOEA   MENORRHAGIA   LMP


5) SEXUAL FUNCTION :-

6) PREGNANCIES, LEBOUR AND PUERPERIM :-

  Gravid   Pregnancy   Abortion   MTP
  FTND(Fullterm)/LSCS(Ceassarean)   HYSTECTOMY   TUBECTOMY   


7) DEVELOMENTAL LANDMARKS AND PROBLEMS :-

8) SLEEP AND DREAMS (ANALYSIS) :-

9) THERMAL REACTIONS :-

  BATH :   FAN:   SUN:   COVERING:   SEASON:   TERMAL:


10) HOBBIES :-
THE MENTAL STATE (PSYCHOSOMATIC AND PSYCHOSOMATIC) LIFE- SPACE INVESTIGATION


DISPOSITION AND EXPRESSIONS INTERPRETATION :-

Nature(Angry, Calm, irritable,sad, happy). Weeping (from which event, incrase or decrease from consolation)
Religiousness, Desire to be alone or company,Will: loves, hates and emotions (suicidal, loathing of life); lasciviousness, revulsion to sex, sexual perversions; fears; greed, eating, honey, emotionality. Smoking, drinking, drugs; dreams; homicidal tendencies, desire or aversion to company, family, friends; jealousy, suspicion, obstinacy, contrariness, depression, loquacity, impatience, conscientiousness.
Intellectual status(memory, concentration, mistakes in writing and speaking), Mood, fears,Understanding: delusions, delirium, hallucinations, mental confusions, loss of time sense.
Social relations And family, Quarrels, competition,ambitions, workaholic(lasy, dull) Confidence level, will etc.


PHYSICAL GENERAL EXAMINATION :-

  WT:   HT:   TEMP:   RR:   P:   BP:
  NOSE:    MOUTH:  TOUNGE:  TEETH:
  THROT:  GLANDS:  NAILS:  SKIN:
  EXTREMITIES:  PALM:  SOLES:  WARTS:


INVESTIGATION :-

  Hb:   RBC:   ESR:   WBC:
  URINE:
  STOOL:
  SPUTUM:
  BIOCHEMICAL:
  REDIOLOGICAL:
  ENDOSCOPICAL:


PROVISIONAL CLINICAL DIAGNOSIS & DIFFERENTIAL DIAGNOSIS(Told by Doctors)

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