Patient'S Case Performa File

PATIENT’S CASE PERFORMA FILE
NOTE: Homoeopathic Treatment is based on the Individual’s

Detailed History and Maximum Information regarding the
Symptoms of the Disease and the Patient. Unusual, Uncommon
Peculiar Symptoms of the Patient are Most Important for the
Constitutional Assesment which includes Mental , Physical and
Emotional details. As Homoeopathic treatment is individual
based and not disease oriented only . So, furnish as much details
as possible to achieve Cure of your problems.
Date :
Patient’s General Information
Patient’s Case Reference

No.
Diagnosis :
Name :
Father’s/ Guardian’s Name :
AGE/Date Of Birth :
Sex :
RELIGION:
MARITAL STATUS :
Single /Married /Divorced
RESIDENTIAL ADDRESS :
COUNTRY :
Nationality :
Telephone No:
Fax No :
Mobile No :
E Mail Address:
Office Address:
Telephones :
Occupation :
Nature of Work :
PRESENTING COMPLANTS ( Main Problems )
1)
What Is The Problem ? 2)
3)
Explain - Causation / Onset Or Origin Of Each Complaint.
( If Known)
Site of The Problem ?
When & How It Started ?
How Has It Progressed ?
Sensations ?
Any Extension of Pains ?
Modalities: ( How Your Problem Gets
Affected ?)
When & How Is It Worse or
Aggravated ?
(Time - Morn, Noon, Eve, Night. Any
Particular Season Etc.)
When And How Does It Become Better
Or Relieved ?
In Relation To Circumstances :
(Rest/Motion/Ascending/Descending/Tur
ning In Bed/ Exertion/Motion-Slow,
Rapid, First Motion, Continued Motion
Etc. Any Other)
Temperature And Weather :
(Heat/Cold/Wet/Weather
Changes/Thunder Storms-Before,
During, After. Etc.)
Position : (Standing/Sitting/Lying(On
Painful Side, On Right Side, On Back
Etc.)/Bending Double Or Any Unusual
Position. Etc.)
External Stimuli : (Touch
(Hard/Light) / Pressure/
Rubbing/Light/Noise/Music/Odor Or
Smell Etc)
Eating : (In General
(Before/During/After) /Hot Or Cold/Any
Particular Food Item Etc.)
Sleep : (In
General/Before/During/After/In First
Sleep Etc.)
Discharges : Like Sweat Etc
Any other problem related to any
other system like :
(GastricRespiratory/Circulatory/Blood
/Nervous/ Urinary, Renal/
Endocrine/Harmonal/Reproductive/
Joints or Muscles etc.)
Recent Investigations & Reports if
any ( Blood, X-Rays, Ultrasound,
E.C.G.,CT Scan, MRI, etc.) :
Can be sent as Attachments also.
Details of the Treatment taken up till now with its effects
- Can be used as attachment.
PAST HISTORY ( Previous Diseases & Their Treatment)

Any significant disease like :
(Typhoid/Malaria/Jaundice/Measl
es/Tuberculosis/Allergies/Chicke
n pox etc.)
Hospitalisation if any : (e.g.
Accident/Disease /Any Surgical
operation?)
Any problem of Diabetes/
Hypertension/ Arthritis/ Asthma
etc.
Any treatment taken earlier , its
duration and its outcome.
FAMILY HISTORY
Any history of same suffering among Blood-related family

members i.e. Parents Grandparents, Siblings, Aunts, Uncles and
Cousins etc. from maternal or paternal side. Specify your relation
with the person.
Any Family History of

Diseases like :
(Diabetes Mellitus , Thyroid /
Obesity, Kidney Failure, Stones)
Arthritis like : (Gout/ Osteo
Aarthritis / Rheumatoid
Arthritis)
Tuberculosis : (Cancer
/Malignancy)
Hypertension : (Heart Problem
/ Angina / Coronary Artery
Disease)
Skin Disease : (i.e Psoriasis /
Vitiligo / Eczema / Urticarea)
Asthma/ Allergic Bronchitis /
Sinusitis / Hay Fever
Anxiety Neurosis/ Depression/
Psychiatric & Mental Disorders /
Schizophrenia , Epilepsy /
Paralysis/ Stroke
Gonorrhoea /Syphillis or STD/
AIDS, Any Genetic problem, or
any other Sickness not
mentioned.
PERSONAL HISTORY
(Kindly elaborate and mention habits, addictions like Alcohol,

Smoking, Tobacco etc.)
Allergies : (If any (Known or Unknown
Allergens specially Any Drug / Food
Allergy )
Tendencies : ( like Cold, Viral,
Infections, Boils etc.) or any other
Are you Vegetarian or Non
Vegetarian ? (Diet - Veg / Non
Veg )
Do you take Eggs ? (Yes / No)
Smoking : (If Yes - How many and
since when ?)
Drinking Alcohol : (If Yes - quantity,

duration and frequency) ?
Any Other Addictions ?
(Tobacco/ Paan Masala/ Drugs etc ?)
Temperature : ( Normal/Subnormal/
Raised) ?
Blood Pressure?
Physical Activities ?
(Walking/Jogging/Swimming/Sports/Playi
ng/ Horse Riding/Wok Outs)
Dancing/Aerobics/Cycling etc. or
others ? (Regular/often /Occasional/
Seldom/Not At All.)
SLEEP : Whether restless/ disturbed/
sound/ position during sleep ?
DREAMS : ( Whether regular /
occasional. Type of Dreams – Pleasent/
Unpleasent/ Frightful/ Day to day
affairs/ Animals/ Snakes/ Water /
Journey/ Accidents / Death / Dead
people/ Sexual – Wet dreams/ Past
Events/ Loss or Missing something
Heights/ Failure / Night Mares etc
Any Other, Explain.
Do you wake up because of dream /
Are you able to sleep again easily
afterwards / Do you have to make
efforts to go to sleep again / Does the
same dream continues again ?
Do you normally remember / forget the
dream ?
What is the effect of Dreams on you
the following
day ?
APETITE : Whether hunger is proper or
not, Any food substance allergic to or it
suits or does not suits ?
THIRST : How is your Thirst? Please
mention the grade of thirst ? If you are
very thirsty, you may mention grades
+,++ or +++ ( Quantity, frequency ,
liking for cold or normal, or
thirstlessness ) ?
TONGUE : (Whether Clean /Coated
/White /Thick/ Ulcerated/ Mapped. Any
Spots - / Bluish/Blackish. Taste in the
mouth – Biiter/ Bland/ Rancid/ Metallic /
Tastelessness/ Sweetish etc. Any
Smell ?)
DESIRE or CRAVINGS : (Mention
grades of preference +,++ or +++ For
example if you like sweets, mention +
or ++ or +++) Sweets, Salty, Sour,
Fried, Spicy, Cold or Hot /, Tea, Coffee,
Milk, Fruits, Eggs , Meat , Fish , Alcohol
etc.)
Anything else Unusual like Mud, Chalk,
Pencils etc, Does it cause any problem ?
AVERSION or DISLIKE to any like
Sweets, Salty,
Sour, Fried, Cold or Hot, Bread ,etc. or
any thing in particular like Meat/ fish/
egg/ milk/ vegetables/ chocolates etc.
Or anything else
URINE (frequency, character, color ,
pain /burning, involuntary urination,
stress incontinence, any complaints
before/during or after urination - Any
Blood, Sediments etc ?
STOOL : (frequency, Bowel
movements, constipation, loose/hard,
any complaints before/during or after
stools. Any Mucus or Blood in stool. Any
pain /burning while passing stool ?
Do you have Piles - Bleeding/ Non
Bleeding/ Painful/Painless/ Single/Bunch
Degree ?
Any Gas formation, Belching like
small burps or loud Eructations and how
you feel after / whether it comes empty
stomach or eating after ?
SWEATING - (More /Less / Normal .
Summers/Winters .Any particular
part.where you sweat more , Odour or
Smell of sweat does it stain the
clothes )
GENERALITIES
State how you are affected by or how you react to the following :
Cold in general, Cold Air, Drafts,
Cold Winds etc ?
Do you like to cover your head
(or wear a cap) when you go out
in the cold or when exposed to
the draft of cold air ?
Warmth in general, warmth of
bed or room, External warmth
like Hot Fomentation etc ?
Weather : Dry , Cold wet,
Rains , Cloudy etc ?
Thunderstorms
Eating and Drinking ( Before,
During and After )
Fasting
Any particular item of Food /
drinks which adversely affect
you or make you sick ?
Closed, Crowded places,
Elevators / Lifts etc.
Exertion or Physical Strain ,
Mental Strain :
Lack of sleep ?
In what part of the day i.e. 24
hours do you feel the Best or
Worst ?
Does your trouble tend to
occur or become worse,
periodically (e.g Daily, or
Alternate days , Weekly,
Monthly, Yearly , during New or
Full Moon etc. )
THERMAL REACTION : (Feel
Heat / Cold more,
Senstivity/tolerance, any
coldness of the Hands/Feet.)
MENTAL STATE ( The Mind)
(It’s very important to give as much details as possible in this

section especially in chronic diseases ).
Do you like to be Alone or in
Company ?
Any Fears or Phobias (of being
alone/darkness/heights/death/ water/
falling/ghosts/ thunderstorms/
animals /thieves / robbers / sudden
noises or any other things .) Specify
How is your temperament ?
(Irritable/ Weep easily/ Sensitive/ get
Angry soon / Depressed./Moderate/
Accommodating / Cool.)
If angry : (What brings the anger,
and what do you do – Shout / Abuse /
Violent / Don’t show and Suppress or
something else - Specify )
Do you weep easily ? Yes /No
(Do you weep when alone or in front
of others ?
How do you feel after weeping?)
What is the effect of consolation on
you ?
Do you share your feelings with
others or keep inside you ?
How about taking Decisions –
Indecisive / Take quick decisions and
stick on them or Wavering ?
Jealous/ Suspicious/ Religious/
Superstitious, if yes, then of what
and to what extent?
How about keeping things Neat and
Tidy /clean ? Any Fault finding in
others ?
Do you worry a lot ? Yes / No
(Even for small things / or take
things lightly )
Do you Brood over things ? Yes /
No
(How does it affects you ?)
Anxiety if any about (What / when/
what happens when you have
anxiety/ does it associate with any
physical problems.
(Sweating/Trembling/Palpitation/
Breathlessness, Sinking etc.
Pls.specify).
Do you get startled easily by sudden
noises , telephone bells, banging of
doors etc ?
Are you very caring by nature or
indifferent ? (Towards family
members and friends etc.) ?
How do you feel when Contradicted ?
Any Guilt or Regrets in life?
Do you Apologies or Not?
Any Negative or Suicidal
thoughts? (Explain and if Yes , any
such Attempt made.
How Ambitious you are ?
Any Non fulfillment of ambition in life
?
How do you like your work ? Like it/
don’t want to do.
What do you think about your
disease?
Do you forgive easily? Keep the bad
things done to you in mind and plan
to give it back when time comes
Revengeful/ Coward/ Brood.
Any Complex about yourself ?
Do you hurry for everything and
become Impatient?
Do you Postpone the things or
become worried with Anticipation ?
How do you rate yourself ? ( Self
Esteem, Haughty, Shy, Rational,
Egoistic, Sympathetic, Conscientious,
Emotional, Strong Headed,
Calculative, Impulsive etc.)
What according to you others think of
you ?
What makes you feel Happy ?
What makes you feel Sad ?
Please mention any Incidence, Mishap , Loss, Betrayal , Death,
Disappointment , Love, Insult, Failure, Depression etc. which has
any impact or relation to your present problem either has
affected you deeply or otherwise also.
SEXUAL HISTORY
Any history of Venereal

Diseas (e.g – Gonorrhoea ,
Syphllis, Herpes , AIDS.)
Sexual Behaviour : (Single /
Multiple Partners; Bi Sexual ;
Homosexual ; Gays; Indulgence
; frequency ; Masturbation etc.)
Any Problem like:
(Impotency; Pains; Erectile
Dysfunctions ; Premature
Ejeculations Partial or Complete
loss of interest in sexual
activities Specify if any other
problem ?)
Desire / Dislike/ Hate to Inter
Course / How does Sexual
activities affect you ?
Any persitent sexual thaughts /
dreams / fanatsises.
GENERAL PHYSICAL APPEARANCE
Built ( Strong, Thin, Stout,

Obese, Average ).
Colour Complexion :
( Fair/Wheatish/Dark/Pale).
Nutrition : ( Well nourished,

Undernourished or Over
nourished)
Height :
Weight :
Swelling or Growth/ Tumour – If
any ?
Part of the Body :
(Hard/Soft /Cystic, Firm or
Mobile. Whether Pitts on
pressing/Non pitting,
Size/Shape/ Inflammation
/Painful/ Painless/
Itching/Burning. Any Discharge -
Pus/Blood etc.)
Modalities
Skin :
(Dry/Rough/Smooth/Oily/Greasy
etc.)
Hair : (Texture etc.)
Nails :
Teeth :
Pigmentation:
Fever : (If have fever ,when
,any periodicity, particular
time, duration of fever, if feel
chilly/ hot/ sweat/ duration of
each phase;any time modality,
thirst, tongue, headaches,
nausea, vomiting, thirst,
appetite, bodyaches
,restlessness if any.)
If feel like covering or just want
to lie down quietly. Any other
complaint with it like burning
,Skin feels hot/cold/clammy.
Any Ghabraahat?
Please mention any thing else pertaining to you and your
problem which you feel has not been asked in the Questionare
and is persistent and unusual, Do mention strange feeling if any.
(All histories ,Case reports are kept Confidential )
Photos can be attached if required.
( Signature )

Patient'S Case Performa File

Uploaded by

Copyright:

Available Formats

Patient'S Case Performa File

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Patient'S Case Performa File

Uploaded by

Copyright:

Available Formats

PATIENT’S CASE PERFORMA FILE

NOTE: Homoeopathic Treatment is based on the Individual’s

Patient’s General Information

Patient’s Case Reference

PAST HISTORY ( Previous Diseases & Their Treatment)

Any history of same suffering among Blood-related family

Any Family History of

(Kindly elaborate and mention habits, addictions like Alcohol,

Drinking Alcohol : (If Yes - quantity,

MENTAL STATE ( The Mind)

(It’s very important to give as much details as possible in this

Any history of Venereal

GENERAL PHYSICAL APPEARANCE

Built ( Strong, Thin, Stout,

Nutrition : ( Well nourished,

You might also like