Rkd’s HOMOEOPATHY.

Case taking form

Reg.no……………………………….. Date………………………………… mobile no……………………………………

Name………………………………………………s/o……………………………………….. Age/Sex………………………………………..

Marital Status…………………………. Religion…………………….. Weight/Hight…………………………………………………

Address……………………………………………………………………………….. Occupation………………………………………………

PHYSICIAN………………………………………………………..

PRESENT COMPLAINTS: (Location, Sensation, Duration, Extension, Modality, Concomitants )

H/O PRESENT COMPALAINT.

PHYSICAL GENERALS:

Appetite: Menstruation (cycle, flow, color, before, during, after)

Thirst:

Salivation:

Taste of mouth: Sleep:

Desires:

Avertions: Dreams:

Intorerance: General modalities:

Stool:

Urine: General tendencies:

Perspiration:

Discharges: General sensation and complaints:

Tongue:

Thermal reaction: (Hot, Chillly, Ambithermal,and not affected by heat and cold)

MENTAL GENERALS:
PAST HISTORY: (Evolution/Preceding the onset of presenting complaint)

FAMILY HISTORY :

Paternal : Maternal :

(Father, Grand Father, Grand Father, (Mother,Grand Mother,Grand Father,

Uncle,Aunty,Brother,Sister) Uncle,Aunty)

PERSONAL HISTORY :

Addiction (Present /Past Duration )

Accommodation; Near by mobile tower, transformer;(mobile,computer/net addiction)

Diet:

Habit and Hobbies :

OCCUPATION :(occupational hazards)

Cooking Utensils :

Relation with family members and in the field of occupation :

Sexual activity:

Any medicine taken regularly (with duration):

History of vaccination[what type of vaccination with effect]

Developmental milestones :

Place born and brought up;

Number of childrens and their ages :

Socio-economic status :

Marital status :

SYMPTOMS OF REPERTORISATION / RUBRICS :

ANALYSIS OF REPERTORIAL RESULT FOR SELECTION OF MEDICINE

FOLLOW-UP SHEET