Case Submission Form

Case Submission Form

www.homeoforme.com
A. Personal Details

Please provide as accurate details as possible.
You are filling this form for

yourself.your family member.someone other than your family member.
I consent to submitting my / patient's personal and health related information to www.homeoforme.com which is to be used for the sole purpose of homeopathic treatment in accordance with its privacy policy.

I consentI do not consent
Name of patient

PrefixFirst NameMiddle NameLast Name
Phone Number

Country CodePhone Number
Email
example@example.com
Gender

MaleFemale
Date of Birth

MonthDayYear
If you are not sure, select a date that reflects close to your current age
Height
Specify unit e.g. 5 feet & 6 inches or 175cm
Weight
Specify unit e.g. Kg or Pounds
Complexion
Build
e.g slim, tall, medium, obese etc.
Occupation
Marital Status

MarriedUnmarried
Medicines currently being taken
Chronic cases: include all medicines taken in past 5 years Acute cases: include all medicines taken in past 6 months Include any alternative medicines taken e.g. Homeopathy, Ayurveda
B. Present Complaints

Describe Location. Extension, Radiation or Migration/ Movement of each complaints. Describe exact nature of symptoms including pain and sensation.
Complaint 1
Also include date or month & year since when your symptoms appeared.
Complaint 2
Also include date or month & year since when your symptoms appeared.
Complaint 3
Also include date or month & year since when your symptoms appeared.
Complaint 4
Also include date or month & year since when your symptoms appeared.
C. Factors that affect your symptoms

Explain which of the below factors makes your symptoms better or worse. Leave blank where not applicable.
Season
example: joint pains increases in winter
Time of Day / Night
example: experience bloating at around 4pm on most days
Temperature, Damp weather
example: during rainy season, coughing increases
Rest, Motion, Riding in car
example: after walking few steps, feel dizzy and nausea
Bathing
example: after a cold bath, joint pains go away
Position (Standing, sitting, lying)
example: on lying, my stomach ache worsens
Pressure, jar, noise, music, light
example: when pressure is applied, shoulders pain feels relief
Specific food (e.g. milk, fatty, spicy, vegetables, milk, etc.)
example: on eating dairy products, rashes re-appear on skin
Sleep
example: after going to sleep, stomach pain worsens
Menses Before, During, After
example: after periods, there is increase in headache
Sweat
example: after sweating, nose blockage generally reduces
Vomiting, urine, bowel movement
example: after urination, abdominal pain increases
Coitus
Anger, grief, fear, consolation
New moon, Full Moon
example: during new moon, my back pain worsens
Local application (Cold, warm, wet)
example: applying warm flannel reduces skin rashes greatly
Accompanying symptoms ( in any other part of body)
example: when knee pain appears, there is also buzz sound in left ear
Which symptoms appeared first? (Drag & Drop)
Any strange or peculiar symptom?
e.g. my toothache gets better by taking cold water in mouth

Case Submission Form

A. Personal Details

B. Present Complaints

C. Factors that affect your symptoms

D. Health Profile: Head to Foot

E. Personality Profile

F. Your Preferences