Adult Patient Questionnaire

In homoeopathic treatment, history of the patient is extremely important. It takes about one hour or more to analyze a case.
We take into consideration both physical as well as mental aspects
of the patient.

As it is now universally acknowledged, our mind has a tremendous influence on our body. For giving proper treatment, it is absolutely necessary to understand the patient’s emotional and intellectual nature/behavior.

In order to get a better insight, the patient will have to answer the questionnaire honestly, carefully and completely. This information will help us to understand the patient, his/her reactions to situations and help us in prescribing him/her the correct remedy and a very positive approach towards life.

We request the patient not to hesitate, introspect and write down everything in detail.

Instructions

• Underline the correct answers

• Patients should write the answers below so that we can preserve the information for future reference.

• If you fall short of space, please feel free to attach an A4 sheet with the question number.

All the information given by the patient will be maintained in complete secrecy.



1. Preliminary Information

  1. Name -
  2. Address -
  3. Contact Number –
  4. E-mail –
  5. Date of birth –
  6. Place of birth –
  7. Time of birth -

2. Chief Complaints

  1. Describe every symptom in detail
  2. Onset and duration
  3. Chronology of symptoms – How did it first begin, progress etc.
  4. Diagnosis, if any made by physician/specialist.
  5. Treatment taken for the disease.
  6. Factors that increase or decrease the intensity of illness.

3. Associated Complaints

  1. Any other complaints the patient experiences

4.Past History

  1. Any major illness
  2. Accidents / injuries

5.Family History

  1. History of disease or any major illness in the family

6. General Information

  • Appetite
  1. Poor / Average / Healthy
  2. Strong likes/dislikes for foods
  3. Tendency to indulge in certain foods
  4. Food allergies (if any)
  • Temperature
  1. More tolerant to-Cold / Hot
  2. Weather most comfortable in?
  3. Weather that makes you uncomfortable?
  • Perspiration
  1. Do you perspire profusely? Yes / No

If yes, where and under what circumstances?

  1. Do you use any of these? - Talcum powder / Deodorants / Perfumes
  • Sleep
  1. Quality of sleep
  2. You wake up - Refreshed / Fatigued
  • Dreams
  1. Do you dream? Yes / No
  2. Do you remember your dreams? Yes / No
  3. What do you dream about?
  4. Do you have recurring dreams? Yes / NoIf yes, describe.
  • Bowels
  1. Frequency - Regular / Irregular
  2. Stool – Regular / Constipated/ Loose
  3. Urine normal? Yes / No
  • Thirst
  1. Liquid intake – (Low / Average / Good)
  2. How often do you feel thirsty?
  • Personal details
  1. Weight
  2. Body structure (Lean / Average / Flabby)
  3. Height (Tall / short)
  • Lifestyle
  1. Addictions / habits?
  2. Do you exercise? Yes / No
  3. Do you like your job? Yes / No
  4. Recreational activities
  1. Sex life
  2. Social life
  3. Spiritual life

7. Personal History of the patient

  • Childhood
  1. Childhood diseases
  2. Your happiest/most painful childhood memories.
  3. Your childhood nature(timid, hyperactive, mischievous, rebellious, etc.)
  • Family
  1. Your relationship with individual family members- If any problems with any of them, explain.
  2. Any insecurities, disappointments or other issues with family members?
  3. Position in sibling hierarchy.
  • Self
  1. Patients clear picture of his/her situation in life
  2. Do you get anxious (nervous / depressed)? Related to what and how do you react to it?
  3. Have you suffered any serious shock / grief / disappointment / fright / mental agony?If yes describe in detail.
  4. Are you worried or unhappy over any personal / domestic / financial / social or any other related matter? If yes, describe in detail.
  5. Your ambition you have/had in life? What difficulties are you facing/have already faced in achieving it?
  6. Your greatest grief you have had in your life?
  7. Your greatest joys / happiness you have had in your life?
  8. Activities that you like / dislike.
  9. Movies / books / dramas / persons that has influenced you the most and why?
  10. What do you like about your job?
  11. Any unwanted thoughts, anytime? Explain
  12. On what matters do you get impatient?
  13. What are you proud of? Does your pride get easily hurt? In what way?
  14. What superiority/inferiority complex do you have?
  15. How seriously do you get affected by disorder / uncleanliness in and around your surroundings?
  16. How is your memory?
  17. What makes you angry? How do you express your anger? What bodily symptoms do you develop when angry (e.g. trembling, sweating, etc.)?
  18. How do you react to contradiction?
  19. How long do you remember when you are hurt by others?
  20. Do you suppress your feelings? When and why?
  21. Do you weep easily? What makes you weep and how do you feel after weeping?
  22. How do you feel if someone offers you sympathy/consolation?
  23. Are you doubtful/ suspicious by nature? Of what?
  24. How revengeful are you?
  25. Any suicidal tendencies? Yes / No

If yes, when? In what manner do you contemplate to end your life? What prevented from doing so? Even then are you afraid of death?

  1. In your opinion which aspect of your mind and moods are not agreeable to you?
  2. Major events that have impacted you adversely?
  3. How does future look to you?
  4. Do you get along well with family / colleagues? If not describe problems.
  5. School and college environment (for teenagers)
  6. Are you anxious / upset / nervous / depressed about any matter in your family / school / college / friends? (for teenagers)
  7. Do you feel that your family members / parents / friends don’t understand you? If yes, explain (for teenagers)
  8. Are you being dominated by your parents? If yes, for what? Please explain. (for teenagers)
  9. Any other issues which you feel important enough to write about yourself, which has so far not been mentioned in this questionnaire?

7. Additional Information (for women)

  1. Age of onset of periods?
  2. Regularity of periods?
  3. Physical symptoms preceding onset of periods?
  4. Duration of periods?
  5. Interval between periods?
  6. What method of contraceptivedo you use?
  7. Discharge before / during / after periods?
  8. Number of children?
  9. Type of delivery?
  10. Post delivery problems?
  11. Problems with breastfeeding?
  12. Any abortions and complications?
  13. Age of onset of menopause?
  14. Did your periods cease abruptly or gradually?
  15. Surgery or other problems with reproductive system?

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