Case-Taking-Format
For patient: it is advice to treat their illness by a good local homoeopath, with the help of our Repertorial analysis chart.
Guide lines:
The patient as well as physicians should always keep in mind that every case is quite new and also that Homoeopathy treats the patients, never the disease by nomenclature. One should not be puzzled to look at this exhaustive case taking Performa. This is meant for all ailments of humanity all over the world. He is to note only that point which concerns him and the rest may be left blank. It is cautioned that answer should be given after due deliberation never in a hurry, the wrong or confused answer will lead to wrong selection of a remedy, which will be harmful, to the patient as well as the physician. If the patient has difficulty in the filling up the Performa, he may take help from good local homoeopath.
Confidential
Name Age Date
Sex Religion
Occupation
Address [present]
Address [permanent]
E-mail number
History of present illness
[Complaint, Location, How it aggravate & relived]
Pathological State Report [if any]
X-ray, blood test, urine test, ECG, Ultrasound, C.T. scan, MRI, memo graph, etc.
Details of past illness & events
[Give as far it is known]
Family History
[Indicate the main disease of family members]
Mental Information
Mental Traumas [write in details if any]
Death of love own, loosing job, unemployment, money loss, hopelessness, honor wounded, frustration, domination, discord, envy, responsibility, family anxiety, carelessness from family members, divorce, indifference, love disappointment, after retirement, and any present problem or mental pressure.
Mental State
Present condition of – memory, concentration, anger [why and type of anger], consolation [agg. or amel.], maliciousness, remorse, fear [from which and why], weeping [why and which type], any anxiety, envy, discontented [from which], escape nature, sympathetic, depressed, fastidious [which kind], postponing nature, company desire or aversion [why], habits, hobbies, religious behavior, crowd and noise [how affects]
Economical Status
Family income, condition of business, future planning, social economical status, avarice, extravagance, satisfied or dissatisfied with his/her income.
Observation
Traits of character, constitution, diathesis, susceptibility, intolerance
Sleep
Nature, position, symptoms [before, during & after sleep], action sleep during [started, teeth grinding, talking, walking, urinating etc], pillow desire [ high, low etc]
Dream
Object, frequency, effect on the patient.
Sex
Continence, desire, aversion, satisfaction, masturbation, ejaculation, perversion if any, marital and pre or post marital relationship.
Menses
Menses appear [age, premature, delayed], cycle [regular, irregular, early, late], duration, character of discharge [colour, consistency, order stain], quantity [profuse, scanty], character of flow [normal, clotted, scanty, profuse, suppressed], symptom [before, during, after menses], alteration if any.
Leucorrhoea
Character [type, colour, order, stain, frequency] character of flow [before, during, after], concomitant.
Symptoms [different part of the body]
Vertigo [when, type]
Head [pain, hair falling, hair gray becoming, tangled, split, lice, dandruff]
Eye [discharge, pain, colour]
Vision [foggy, blindness]
Ear [discharges, pain]
Hearing
Nose [discharges, smell, dryness, sneezing, sinus]
Face [dry, oily, colour, lips]
Mouth [taste, smell, salivation, open sleep during, gums]
Tongue [colour, moisture, coating, sides and under surface]
Teeth [ carries, colour, sensitiveness]
Throat, tonsil
Stomach [appetite, thirst, digestion, eructation, nausea, yawning]
Abdomen [gas, distended, hardness, ball sensation, liver, spleen]
Rectum -- inactivity, piles, fistula, prolapses
Stool [first urge when, type, frequency, satisfactory or not]
Urine and urination [frequency, flow, pain, burning, retention, colour, order, sedimentation]
Prostate,
Breathing
Back
Respiration
Cough
Extremities [pain, restlessness, numbness, cramps, finger nails, hardness]
skin [eruption, eruption if any, itching, discoloration, warts, tendency to suppurate, scars]
perspiration [location, quantity, order, color, stain on cloth]
Cold
Fever [chill with, entrainment, thirst, restlessness]
General symptom
Which season patient like, dislike and why? How change of weather affects? Bathing [likes or dislike]? Likes open or close place? Clothing loose or tight? Which color attracts or why? How heat, light, humidity, sunlight, affects? Food - desire, aversion and aggravation.
Child case taking format.
Name Age Date
Sex Religion
Study NORMAL / CISSARIAN BABY
Address [present]
Address [permanent]
E-mail number
History of present illness
[Complaint, Location, How it aggravate & relived]
Pathological State Report [if any]
X-ray, blood test, urine test, ECG, Ultrasound, C.T. scan, MRI, memo graph, etc.
Details of past illness & events
[Give as far it is known]
Family History
[Indicate the main disease of family members]
Mental Information
Mental Traumas [write in details if any]
Death of love own, honor wounded, domination / excessive parental control, discord, envy, responsibility, family anxiety, carelessness from family members, indifference, any present problem or mental pressure.
Mental State
Present condition of – memory, concentration, anger [why and type of anger], consolation [agg or amel], maliciousness, remorse, fear [from which and why], weeping [why and which type], any anxiety, envy, discontented [from which], escape nature, sympathetic, depressed, fastidious [which kind], company desire or aversion [why], habits, hobbies, religious behavior, crowd and noise [how affects]
Sleep
Nature, position, symptoms [before, during & after sleep], action sleep during [started, teeth grinding, talking, walking, urinating etc], pillow desire [ high, low etc]
Dream
Object, frequency, effect on the patient.
General symptom
Which season patient like, dislike and why? How change of weather affects? Bathing [likes or dislike]? Likes open or close place? Clothing loose or tight? Which color attracts or why? How heat, light, humidity, sunlight, affects? Food [desire, aversion and aggravation].