Franchisee Clinic : Reg. No. Dr.MANU'S® HOMEO CLINICS MULTI SPECIALITY HOMEO CLINICS CASE TAKING Name: Age: Height: Weight: Pulse: Address : Contact no: Occupation: Mother tongue: How the appointment is taken(i.e.telephone, referral, ads, call center, etc): Way of entering(ex.Timid, bold, fast, slow. etc) Expression(ex.Smilling, serious, anxious, etc) The way the patient greets you(ex.Reverence, haughty, affectation, gestures, etc) Patient explaining- his complaints in any order along with mental complaints, behaviour.Present complaints : (layer wise): 7” layer- 6" layer- 5” layer- 4” layer- 3" layer 2” layer- 1" layer- Each complaint--duration/since how long? OA ROeNna 7. In detail: Duration of pain- Character of pain- Side-how pain comes and goes- Extension(from left to right or vice versa) Modalities: Investigations: List of investigations:How the reports are arranged (ex. Fastidious, helter / selter)? Past history: What was the major or minor illness in the past? Drug history (if any including side effects) Anything particular like never well since last attack of typhoid? Journey of disease (ex. fever --- sinusitis ---- backache ~ Aliments from emotional state affecting body parts ~- diabetes — piles—....Journey of disease in chronological order: Family history: Hereditary illnesses: Father: Mother: Brothers Sisters: Sons: Daughter: Wife: Relatives(uncles, aunts, grandparents): Gynaec history: Menses: Age of menarche- Age of menopause- Character of blood- Pains during menses- Hysterectomy, if any then why? Miscarriage, abortions, MTPS, etc Mental state before/during/after mensesLeucorrhoea with characteristics: Obstetric history (like illness during pregnancy, type of delivery, etc): Generals: Appetite: Veg / non veg Tolerance with respect to hunger kind of food |.e. cold, warm or anything Ok Food and drinks (desires and cravings) Food and drinks which agg. and amel- Aversion in food and drinks: Thirst: (Quantity of water intake(with thirst, without thirst, habit) (Quality or nature of water preferable i.e. cold, hot, normal) Perspiration:(profuse, scanty): Odour- Staining to clothes- Stool: No of times- Consistency- Character-(painful or normal) Odour Urine: No. of times- Consistency- Character- Odour-Thermals: Tolerance- Intolerance- Grading Hot Chilly Sleep: Position- Duration- Character(restless, disturbed easily) Dreams: Habits: Mental state: Speed - (in taking , walking, movements...) Expression of the face- Eye contact- Narration of symptoms (ex. smiling, laughing, weeping, childish) Sitting posture- Gestures- Expression(reserved, timid, bold, inexpressive)- Dressing- Mental sensitivity To: Rudeness Criticism Relations Social position Money Admonition Appreciation Ego Affection Sensitivity in generals: Hearing NoiseSun Wind Light Touch Clothing Perfume Pain Rain Moon Food and drinks Vision Smell Others Mental nature: Observations (ex extrovert. introvert, expressive, haughty, timid, reserved, etc) Talking-(loquacious, theorizing, lamenting, vivacious, reserved) Mixing with people- Expressing their feeling or not will: (support want of, responsibility, courageous, confident, weak, dependant, timid) Intellect : (sharp, slow, dilligent, non-diligent) Morals: (good, bad, characters):Life Situation(since childhood till date): (complete story) Infant: Childhood: Teen age: Adult age: Married life:Old age: Physical appearance: Hair: Forehead: Eyebrows: Eyes: Ears: Nose: Lips: Teeth: Tongue: Cheeks: Chin: Neck: Shoulder: Upper arm: Elbows: Built(lean, thin, obese, tall, stout): Shape of the face- Wrinkles- Speech Movement of face while talking Hand shake- Forearm Palms and fingers: Chest: Belly Hips: Thighs: Knees: Legs: Toes: Skin: Hair distribution allover the body: Nails Scars Moles 10Side Affinity: Probable rubrics (min. 10 rubrics) Diagnosis: Miasm: Probable remedies: Remedy selected: 11Follow - Up Date Clinical Observations Treatment 12Follow - Up Date Clinical Observations Treatment 13Follow - Up Date Clinical Observations Treatment 14Date | Amount Paid | Rt No. Balance Dou DOE | Patient Sign | PRO SignDate | Amount Paid | Rt No. Balance Dou DOE | Patient Sign | PRO Sign