MEDICAL HISTORY FOR HOMEOPATHIC TREATMENT OF ADULT.

CHIEF COMPLAINT - (required)
Aggravated
Ameliorated:
Accompanying complaints
PRELIMINARY INFORMATION
Please supply following information about you as standard routine
Name -
Age -
Sex - Male Female
Vegetarian - Non-vegetarian - Eggs -
Habits: (Tick the correct options) Tea Coffee Tobacco Beer Alcohol Others Specify
Family History - (Mention all relatives with whom you interact)
Hereditary/Genetic disease
Mention reason of Death of any members if not alive
Occupational History
Current occupation
Education
Address
Telephone
POSTPARTUM HISTORY
(Tick the correct options) Normal Forcep C - Section
Menstrual history
Family History (Mention all relatives with whom you interact)
Hereditary/Genetic disease
Mention reason of Death of any members if not alive
PAST MEDICAL/SURGICAL HISTORY
Dietary/Food
Desire and aversions if any
GENERAL ENVIRONMENT Hot Water Cold Water Situational
Sleep and dreams
Habits
Daily activities
Perspiration
Thirst
Stomach infections – (Tick the correct option) Nausea Vomiting Gas Pain Normal NA
Emotional nature
Enclosures
1. Medical report and diagnosis of your physician.
2. Copies of reports of investigations done.
3. X-ray reports, Electrocardiograms, EEG, etc

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Dr. Kalpana Kotecha | E: kalpanakotecha@gmail.com | T: +91 9323616462 | Skype id:kalpana.kotecha