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Case Record Form

Dr. Pradosh Kumar Das  M.B.B.S.,M.B.E.H.

                                          Consultant Homoeopath

               JABALPUR. (MADHYA PRADESH) INDIA PIN – 482005.


Mobile No. : 9827517030 & 8109719163 • Medical Emergency. : 8827398387 Res. : 9301957972

My Websites :-,,,,,,

My Email ID :-,,

Instructions to fill in the Case Record Form

Homeopathy is a holistic science based on concept of individualization. In order to find out accurate

homeopathic medicine, it is essential to understand not only your complaints but also your entire

personality, your emotional state, your stresses, your relationships as well as effects, likes and dislikes

pertaining to food climate etc.

Incomplete information will make correct choice difficult. You are therefore requested to supply the

Information without keeping anything back as irrelevant or of little importance. The history that you provide

Becomes basis for further inquiry. Present photograph or a Video may be attached to understand the present condition of the patient.  Hence, we earnestly request for your full co-operation. All information

Supplied, of course, will be strictly confidential.

This information will help us in rendering you the best possible service.



CASE REFERENCE NO. :                                                                                                   DATE :..................


NAME                                                                                    SURNAME


AGE SEX M/F PRESENT WT. _____ Kgs. & HT. _______ Cms.

NATIONALITY MARITAL STATUS.: Single / married / widow / widower / divorced






E-mail :









(Give in detail if any of your blood -relatives i.e. parents, grandparents, siblings, aunts

and uncles are suffering or have suffered from the following ):



Hay fever

Sinusitis, cold

Allergic bronchitis





Osteo- arthritis

Rheumatoid arthritis

Cancer/ malignancy

Diabetes mellitus


Coronary artery disease, Angina etc.


Gonorrhea/syphilis or STD

Psychiatric & Mental Disorders


Anxiety neurosis/Depression

Any other sickness not mentioned above ?


Kindly elaborate and mention habits, addiction like alcohol, smoking, tobacco etc.

veg / non-veg / eggs/

Appetite :

Cravings & Aversions in food :

Mention grades of cravings as per intensity of craving / aversion +,++ or +++ and aversions -,--or ---

for example if you love sweets, mention +or ++ or +++, if you dislike mention - or --or ---


Salty food

Do you add Extra salt in your food ?

Sour things /pickles

Seasoned and spicy



Fried and fats

Any other cravings in food ?

How is your Digestion ?

Any complaints after eating ? For example... Fullness of abdomen, Gas formation or Diarrhoea after eating

Do you feel bloated, full and heavy after eating?

Can you remain hungry for hours on end without food ?

Do you get irritable with hunger?

Does any item of food causes any discomfort eg. Acidity headache, flatulence etc.

Thirst :

How is you thirst ? please mention the grade of thirst if you are very thirst, You may mention grades+ + or


How much water do you take at a time ?

How many times per day?

Your preference in drinks : please mention the degree of craving+,++or +++ would you prefer cold

/chilled water or drinks even in the height of winter would you like your cup of tea /or coffee piping hot or

just normal warm how many cups fo tea / coffee do you generally take in a day Any aversion to any drinks?


State how you are affected by or how you react to the following :-

1. Cold in general, cold air, drafts, cold winds etc .

2. Do you like to cover your head (or wear a cap) when you go out in the cold or when exposed to draft

of cold air?

3. Warmth in general, warmth of bed or of room, external warmth like hot fomentation etc.

4. Weather. Dry, cold wet, Rains, Cloudy etc.

5. Thunderstorms

6. Open fresh air likes/dislikes

7. Near the sea /on mountains

8. Eating and drinking (before, during and after)

9. Fasting

10. Any particular item of food /drinks which adversely affect you or make you sick

11. Closed. crowded places, elevators /lifts etc.

12. Exertion or physical strain, mental strain

13. Lack of sleep

14 . In what part of 24 hours do you feel the best or the worst

15. Do your troubles tend to occur or become worse, periodically (eg. daily or alternate days, every

week, yearly, during new or full moon etc.)


Do you regularly have a satisfactory bowel evacuation?

How many times do you move the bowels? when?

Consistency: whether
□ well formed  
□ semi- formed
□ very hard
□ loose Odour

colour of stool any straining required or stool even though stool might not be hard or constipated?

Any urgency for stools (eg. do you have to run for stool first thing in the morning or immediately after

eating ?

Any pain burning bleeding with stool Piles /fissure /fistula ?

Do you have flatus (wind) when passing stool and is the stool noisy and spluttering?


Frequency , day and night

Any burning during urination?

Any smell (odour) in the urine?

Any difficulty in passage of urine?

Any difficulty in retaining urine ? Do you have any incontinence while coughing or sneezing ? Is the urine

very urgent and you must rush immediately or it will escape ?

Any associated complaints with urination ?


- Any sexual disturbance ?

Excessive desire or aversion to sex

Disability of performance, premature ejaculation etc.

Night emissions

Any history of sexual abuse, excessive masturbation etc.

Any complaints after intercourse ? Weakness after intercourse, Backache after intercourse

- Any sexual disturbance ?

Excessive desire / aversion to coitus ?

Any leucorrhoeal discharge ? Itching, burning or discomfort associated ?

Any sense of 'bearing down' at the time of menses ?

How many times have you been pregnant ?

How many children do you have and their age ?

Did you have smooth pregnancies ?

Did you take any medication during pregnancy ?

Did you have normal deliveries ?

Age of appearance of first period (Menarche)

How are the periods ? (regular or irregular)

What is the duration of your period and how many days cycle ?

How is the flow ? - (scanty, heavy, clotted, any odour, colour)

Any PMT (Pre-menstrual tension)? Do you have any complaints associated with, before or after menses ?

Eg. Moods changes, Headache, Irritability, Anger, Weeping, Depression, Diarrhoea or Constipation

Any changes in your skin around menses ?

Any heaviness or pain in breasts before menses ? Any nodules in the breast ?


Age of menopause

Any associated complaints at the time of menopause eg. Hot flushes, coldness Palpitation, Anxiety,

Depression etc.


Do you perspire a lot ?

Any particular part of the body that you perspire more on ?

Any strong / offensive odour associated (eg. Sour smell) with the sweat?

Does the perspiration stain the clothes ? eg. yellow stain on clothes


Do you sleep well ?

Any particular posture in which you lie the most when you sleep ? eg. Lying on the sides (right or left) back

or on your abdomen, curled up etc.

Do you feel refreshed after sleep ?

Do you dream while sleeping ?

Any particular dream that is recalled and often repeated ? (eg. Frightening dreams of falling from a height or

being pursued by some men, or dead people or relatives water, religious, temples etc. )

Does any of your complaints get worse or better before, during or after sleep ? eg. Cough or asthma attack

that wakes you up at night or migraine or waking in the morning. Hot flushes just as you begin to fall asleep.


Any skin problems that you have or had earlier (eg. Allergies, eczema, fungal infections, pigmentations,

acne, etc.)

Any itching or discoloration associated with it ?

Any factors which worsen the skin problem ? eg. Any item in food, any weather conditions or washing with

warm or cold water.

Any treatment taken for it and its details ?

Any complaints or abnormality of Nails or the skin around nails ?

Any complaints of Hair falling, early graying, dandruff, thinning etc. ?

Any warts, moles, birth marks on the body ?

Does your skin heal normally after an injury or takes very long to heal ?

Any tendency to form excessive scar tissue (Keloids) ?

Any tendency for wounds to suppurate (form pus easly) ?

Are you applying any local ointment or cream on body?


(It is very important to give as much details as possible in this the Performa especially in chronic diseases)

Have you noticed any marked changes in your mental state lately? If so, describes It in detail please. Have you

become or are.

1. Anxious /afraid of anything eg. Being alone , animals, darkness ,disease ,thieves ,robbers, sudden noises,


2. Do you get startled easily by sudden noises, telephone bells, banging of doors etc.

3. Suspicious, doubting

4. Impatient or hurried and hasty do you eat hurriedly and there is always a sense of hurry?

5. Offended easily (cannot take any criticism)

6. Are you critical of others, always finding faults

7. Irritable, quarrelsome, violent etc .

8. Depressed easily, sad, gloomy

9. Timid /shy/bashful / embrassment

10. Jealous or suspicious

11. Anxious, restless, nervous or excitable

12. Do you fell very anxious and apprehensive before examination, before stressful situations, public

engagements etc.?

13. Are you silent, quiet, reserved or talkative? Do you make friends easily?

14. Are you very affectionate? Do you demand love and warmth from others?

15. Do you cry easily? What makes you cry (grief of others, music kind words .of affection etc.)

15. Are you very sympathetic in general and go out of your way to help people in need? Are you easily moved to tears at the plight of others?
16. If someone consoles you when you are upset, does it help or does sympathy towards you makes the

matters worse?

17. How do stand and react to contradictions ?

18. Are you an authoritative person, always in command and giving orders and expecting them to be

followed by everyone around you ?

19. Any imaginary fears or feelings ? (eg .that someone might want to harm you or hurt you and that

people are against you?)

20. How is your memory, power of concentration and mental ability ?

21 Do you fell humiliated or hurt easily? Would this give rise to any physical complaints?

22. Are you over conscientious about details, cleanliness, tidiness, punctuality etc.? are you a

perfectionist by nature , being menticulous , fastidious and even fincky?

23. what is the greatest grief that you have felt in life ?also what are the greatest joys in life you have


24. Can you mentally relax easily ? for instance, can you switch your miad off work ,problems, children

etc.? do you enjoy vacation? And can you totally relax when on a holiday or do thoughts of work or

what is happening at home keeps bothering you etc.

25 At work or with colleagues, subordinates or your boss or seniors how do you equate with them?

Would reprimand or scolding from them upset you tremendously? if so how?


Disease Medicine prescribed System of therapeutics


Laboratory tests

X-RAY SCANS, MRI etc. others

In case if you have any queries feel free to contact us at : Tel. :9827517030  • 8109719163 • 8827398387