Case Taking Form

This form is only to be filled in and submitted by patients residing in India and Abroad

Please provide all information in detail and help us serve you better.


DR ANUTOSH CHAKRABORTY'S Expert Homeopathy [A Clinic of Advanced Pain Solution and Chronic Disease]

(FULLY CONFIDENTIAL)



15, Sashi Bhusan Banerjee Road, L.I.C Market, Silpara(west) Kolkata –700008, West Bengal, India   

31/1D, Sisir Bagna Road, Behala, Kolkata-700034, West Bengal, India

CASE TAKING FORM

THIS CASE TAKING FOR THE CHRONIC DISEASE WHO ARE SUFFERING FROM LONG TIME AND DOES NOT GET SATISFACTION

WELCOME TO THE WORLD OF HOMEOPATHY

& EXPERIENCE GENTLE, RAPID AND LONG-LASTING RELIEF/RELIEF!!

Don’t you think you have a right to live a healthy and happy life??

Read & Reply to every point carefully, because it concerns YOU.

All details are confidential and limited only to people who really care for health.

Kindly remember, the quality of treatment or result that we provide to you depends entirely on the quality of the information that we receive from you through the form. (Since we are not seeing each other face-to-face)

 

 

Investing 1 – 2 hours of your valuable time will help secure your lifelong health!!

If you think it is too much to do in one attempt, do it in parts but with full concentration and commitment

HELP US TO HELP YOU BETTER!!

 

PERSONAL DETAILS

 1.      NAME:

 

2.      SEX:

 

3.      AGE:

 

4.      ADDRESS WITH CONTACT NO:

 

5.      BIRTHPLACE:

 

6.    OCCUPATION:

 

 

 

HISTORY OF PRESENT  ILLNESS:   

                                                                                             

Describe your present complaint Include the location, which part is affected? E.g.: Right forehead, lower abdomen, etc.

 




a)    Describe the type of pain or sensation of discomfort that you feel. E.g.: Burning sensation, cramping pain, tingling, numbness, tightness, coldness, etc.

 

    

b)   How did the problem begin (origin)? What could be the probable cause? E.g.: After exposure to cold wind, after eating oily food, after the loss of job, etc.

 

 

c)    How long has the problem been there (duration)? E.g.: 2 days, 4 weeks, 8-10 years, etc.

 

 

d)   What is the progress of the symptoms since they began? Have they become worse or better? If yes, how fast or slow? Have they spread to other parts?

 

E.g.: Started with a right-sided headache 4 days ago. Later, spread to the left side 2 days ago. Developed nausea after eating yesterday. Today, there is also, pain in the right ear.

 

 

e)    What factors aggravate or worsen your symptoms? Eg: By applying heat or cold; by resting the part or moving it; after sleep; in a closed room; Sun exposure, etc. (This info is very important for treatment – so think carefully and reply)

 

 

f)     What factors ameliorate your symptoms or make you feel better?

E.g.: Applying pressure; Massage; Heat or Ice; lying down; keeping the mind busy; etc

 

g)   Are your symptoms worse or better at any particular time? Eg: Worse at 11 a.m.; better in the evening; worse between 4 and 8 pm; better at night; etc. Are your symptoms worse in any particular season? E.g.: “Joint pains occurring in the winter season, better in summer”; “Annual eczema in December”

 

 

h)   Any other comment …

 

 

7.    DISCOMFORTSOTHER  ASSOCIATED  OR COMPLAINTS:

Describe all other complaints besides the main complaint. Describe each one in the same manner as you describe the primary complaint. (Describe everything that bothers you at length)

E.g.: Headache associated with cramping pain in the abdomen.

 

 

 

 

 

 

 

 

8.    PAST HISTORY: History of any major illness, injury, or operation in the past. Describe its impact on you &at what age you had it?

Illnesses suffered in the past

E.g.: Tuberculosis, Typhoid, Malaria, Jaundice, Ring-worm, Urticaria, Measles, Mumps, Herpes, Chicken-pox, etc…

Injuries

E.g.: Fractures, wounds, bites, etc.

Surgeries

E.g.: Removal of appendix or tonsils or uterus, etc; plating of fracture, etc

Any other significant history

.

 

 

9. FAMILY HISTORY: History of major illnesses in other family members such as parents, siblings, grandparents, cousins, uncles, aunts, etc.) E.g.: Grandparent with history of diabetes OR Maternal aunt with history of Schizophrenia(mention their present age and more details)

DISEASE NAME

Asthma

Allergies

Heart Disease

Cancer

Diabetes

Hypertension

Stroke/Paralysis

Tuberculosis

Any other disease

 

 

 

OCCUPATIONAL HISTORY: Type of occupation and what stresses are placed on you by this employment.

Office Factory □ Hotel □ Shop □ Self-employed□ Other:

 

9.    HABITS:(Please specify the quantity, frequency & duration) Eg: Smoking 4 cigarettes a day for the last 2 years.

Smoking

Chewing Tobacco / Pan

Pan Masala

Alcohol

Recreational Drugs

Any other peculiar habit

E.g.: Frequent hand washing, repeatedly checking door at night, nail biting, eating indigestible things like chalk, slate, mud, etc.

 

 

PERSONAL/SOCIAL HISTORY:

a)    RESIDENCE

 

Describe the area in brief

E.g.: Flat on 5th floor of an apartment in resident-cum-commercial complex

Pollution type

E.g.: Air pollution, water pollution

Pollution level or grade

The climate in the area

Mostly dry, mostly humid, extreme summers and winters, etc

Do you have any pets? Specify

E.g.: German Shepherd dog, Persian cat, tortoise, rabbit, etc.

 

 

 

b) FAMILY SETUP WITH DETAILS OF EACH FAMILY MEMBER

 

Name

Age

Relation

Work

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


GENERAL HISTORY:

c) APPETITE:


d) FOOD ALLERGIES: Are you allergic to any specific food? E.g.: seafood, peanuts, eggs, wheat, milk, etc.



e) CRAVINGS: What types of food or tasted you like very much e.g. Sweets, Salty, Spicy,      

Eggs, Fish, Curds, Fruits, etc.? To what intensity or degree? Any particular taste that you desire strongly? E.g.: Raw, Cooked, Warm, Sweet, Sour, Salty, Spicy, Bitter, etc. Do you add extra salt to your food? Eg: “I have sweets even after meals”; “I must have something sweet”; “I always add extra salt to my food”. What temperature of food do you prefer? E.g.: “My food must be hot. I can’t eat it once it becomes cold.”

I have the following unique Cravings:-

 

 

f) AVERSIONS:  What type of food or taste do you particularly dislike or detest? To what intensity or degree? Any food that doesn’t suit you or causes any trouble? E.g.: Aversion to milk dislikes meat, intolerance to eggs, aversion to sour foods, etc.: “I can’t even have one drop of milk since childhood” OR “If I have an egg, I develop rashes all over my body.”

(For intensity, grade from 1 to 3 where 1 stands for minimum and 3 for maximum intensity)

IF Hungry: I hate Cold Foods, Cold drinks, or small-time passes snacks. Hate Intensity: 3

 

 

g) THIRST: How much water do you consume in a day? How much at a time? At what intervals? Do you prefer your water at room temperature or hot or cold?

E.g.: Thirst for small quantities of cold water frequently. Drink about 1.5 litters in a day.

 

h) STOOL: Are your bowel movements regular? How many times a day do you pass motions? Any difficulty or pain while passing motions? Do you pass any blood or mucus in the stool? Any peculiar smell? Do you have constipation or loss motions? Any other issues related to stools or bowel movements? Do you feel fresh after passing motions?

Eg: Straining for stool with occasional bright red blood. “I have regular motions twice a day” OR “I pass a stool after 3 days – I am severely constipated.”

 

 

i)   URINE: How many times a day do you pass urine on an average? Any difficulty while passing urine? What is the color of the urine? Any peculiar smell to the urine? Any other issues related to urine or urination? Any burning, itching, or other abnormal sensation?

E.g.: Urine dark brown in color since 3 days with fishy smell passed 7 to 8 times in the day and 2 to 3 times at night.

 

 

j)    PERSPIRATION: How much do you perspire? Do you perspire more on any particular part/parts of the body? Eg: Armpits, forehead, palms, soles, etc. Does it occur at any particular time or is it related to any particular activity? E.g.: At night, after meals. Does it stain your clothes? Any peculiar smell?

E.g.: “I have excessive sweating especially on the neck and palms after slight exertion” OR “My sweat smells like garlic” OR “Sweat leaves yellow stains on white clothes”

 

 

k) THERMALS: Do you feel uncomfortable in a hot or cold climate? Does sun exposure/fan exposure/AC exposure affect your health & how? Which season do you like the best? In which season does your complaint get worse or better? Do you prefer to cover yourself while sleeping at night or not? Do you prefer the fan/AC or not?

E.g.: I prefer winters with AC on during summers. Cannot tolerate direct sun exposure. Need a thin blanket to cover during the night.

 

 

Summer

Winter

Monsoon

Fan desired (No/Slow/Fast)

Air-conditioning (Must have/ can tolerate/ cannot tolerate)

Covering during sleep

(Thin/thick blanket)

Drinks (Hot/cold) preferred

Bathing with hot/warm/cold water

Sun exposure (No effect/ aggravates/ feels better)

Covering of feet (Yes/No)

 

 

l)    SLEEP: How many hours do you sleep at night or in the day? Do you feel fresh on waking up in the morning? Is your sleep peaceful or disturbed? Which position do you prefer to sleep in?  Eg: On the back, on the stomach, hands stretched up, etc.

E.g.: I usually sleep for 6 hours at night and wake up refreshed in the morning. Sleep is peaceful. I sleep on the sides and back.

 

 

m)   DREAMS: What type of dreams you usually get right from childhood? Do you remember them on waking or not? Any recurrent dream? Any persons (alive or dead) seen in your dream often?

E.g.: Dreams of being attacked, dreams of snakes dreams of trying to catch a train or bus but failing to do so, etc.

 

 

n)   FEARS: Do you have any strong and persistent fears? Are you scared of any animals, insects, darkness, height, water, robbers, persons, etc. (mention of childhood fears too)?

E.g.: Fear of dogs, dark, being alone, heights, crowded places, etc.

(For intensity, use grading from 1 to 3 where 1 stand for minimum and 3 for maximum intensity.)

 

 

                                                                      MIND

It is now universally acknowledged that your mind has a tremendous influence on your body. Forgiving proper treatment, it is absolutely necessary for us to understand your emotional and intellectual nature; we can thus treat you as a whole. In order to understand you, we will be asking certain questions, answer them freely, carefully, and completely. This information will help us much in giving you the correct remedy. Also, such a remedy will help improve your mental makeup.

Are you anxious? About which matter?

Are you fearful of anything such as animals, people, being alone, darkness, disease, robbers, sudden noises, thunder, about future, high place, etc.

Are you doubtful or suspicious? Of what?

What are you jealous about?

In which matter are you impatient? Hurried?

How long do you remember hurts caused to you by others?

How much revengeful are you?

What are you proud of? Does your pride get easily hurt?

Depress, Brooding, etc?

Do you ever become suicidal? When?

Any unwanted thoughts any time? What are they?

Have you any imaginary sensations or fears?

Do you hear voices or that you are called or anything else in this like keeps on occurring in your mind?

How is your memory?

Do you weep easily? What makes you weep?

How do you feel if someone offers sympathy and consolation?

Are you easily irritated?

What makes you angry?

Do you like company? Or like to remain alone?

How seriously are you affected by disorder and uncleanliness in your surrounding?

Are you worried or unhappy over? Any personal, domestic, economic, Social, or any other condition? If so describe in detail.

 

CLINICAL HISTORY:

BLOOD PRESSURE:

PULSE:

HEART SOUND:

CHEST:

TEMPERATURE:

WEIGHT:

TONGUE/ TONGUE PICTURE FOR ONLINE CONSULTATION:

THIRST:

ANAEMIA/JAUNDICE/CYANOSIS/OEDEMA

 

 

FOR FEMALES ONLY

a)   MENSTRUAL HISTORY:

At what age did you have your first menstrual period?

 

Are your cycles regular or irregular?

 

How many days does your period lasts on average?

 

Is the bleeding heavy or scanty?

 

What is the color of discharge? E.g.: bright red, dark red, blackish, or pale?

 

Are the stains difficult to wash off?

 

Any problems you face before, during, or after your periods? E.g. Backache, headache, excessive irritability, and mood swings, etc.

Do you have any white discharge (leucorrhoea) before, during, or after your periods?

 

What was the date of the first day of your last period? (LMP)

 

 

 

b)GYNECOLOGICAL HISTORY

Any discharges before, after, or in between menses? Describe the nature, color, odour, consistency, etc.

Methods of contraception used if any

Any existing or past gynecological condition?

 

 

c)   OBSTETRIC HISTORY

Number of pregnancies

Living children

Abortions (If Any)

Miscarriages

Full-term / Premature deliveries

Normal /Caesarean

Sickness during pregnancy: E.g.: Excessive vomiting, swelling of feet, varicose veins, etc.

Any medical condition during pregnancy: E.g.: Anaemia, diabetes, blood pressure, infections etc.

Complications during pregnancy or delivery: Placenta Previa, obstructed labor, etc.

Medicines are taken during pregnancy if any: Antibiotics, allergy medicines, fever, etc.

 

11.  PERSONALITY: How would you describe yourself as a person? Your emotional aspect. How do you feel and react in various life situations in your daily life? E.g.: You can describe your anger. What are the things that make you angry? How do you express your anger? Similarly, anxiety, sadness, happiness, love, hatred, fears, disappointments, frustration, suspicion, etc. Please describe your nature, behavior, relationships, etc. (Envy, jealousy, suspicion)

Try to portray a picture of your personality without judging as good or bad. (Min. 300 words)

 

 

 

 

 

 

12.  CHILDHOOD: How was your childhood? What are your memories of your childhood? Describe your relations with family, friends, and teachers at present and in the past. Important or significant events during childhood that you recollect now? (Min. 200 words)

 

 

13.  SIGNIFICANT LIFE EXPERIENCES/EVENTS(Eg: Discords, Humiliation; Fights; Deaths; Separations; Divorce; Monetary Loss in business; loss of job, etc.) Describe events that had a major impact on your life. Express how you felt then and now about these events.

 

 

14.  Please note that you may have some symptoms/complaints that may seem unrelated to your main problem/s. From a homeopath's perspective, each symptom is important, however trivial or obsrelief it may seem. Each disrupting symptom – physical, emotional, or mental – could be important for selecting your remedy and therefore should be mentioned to us.

E.g.: A person coming for treatment of his skin allergy may have dreams of snakes, which on the face of it looks unrelated. However, it may be an important clue for treating skin allergies.

Describe unusually symptoms like

a)    Playing with knives.

 

b)    Laughing at serious matters.

 

c)    Terrified of dogs. If I see a dog, I cross the road.

 

d)    I wash all the bed sheets immediately after the guests who slept on them leave.

 

e)    I feel there is a hole in my brain.

 

f)     My body feels double.

 

 

 

 

 

15.  DEVELOPMENTAL MILESTONES (Can take help of parents or grandparents)

Birth weight:

When did you start walking?

When did you start talking (first word)?

When did your first tooth erupt?

Were the milestones delayed?

Any other problems or illnesses during early developmental years? E.g.: Illness such as jaundice, TB, chickenpox, measles, etc.


ADDITIONAL INFORMATION (if any)



ENCLOSURES

 

a)    Medical reports or Consultations:

b)    Investigation reports

c)    Investigation plates: E.g.: X-ray, USG, CT scan, etc

[Attach photographs, reports (scanned copies), videos with file name format in which submitted. Tabulate comparative submissions.]

 

 

DISCLAIMERS:

Treatment given is based solely on the information provided by the patient. It is entirely the patient’s responsibility to provide accurate and complete information.

All outstation patients, in case of emergency, must immediately seek medical help and visit the local hospital.

Medicines sent outstation may take some time to reach depending on the delivery services available.

 

DATE    AND   PLACE:

SIGNATURE OF PATIENT / OR GUARDIAN:

 

FOR PAYMENT, PLEASE CONTACT THROUGH EMAIL WHEN IT WILL UPLOAD FOR TAKING TREATMENT…

HOW TO PROCEED? PLEASE SEE  ONLINE CONSULTATION IN WEBSITE

 Verified By: DR ANUTOSH CHAKRABORTY

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