PLEASE READ THIS FIRST BEFORE
FILLING THIS FORM
You have to get well. We are here to select the
best possible medicine for you .In order to do that,
we depend on your co-operation. HOMOEOPATHIC MEDICINE
IS MAINLY SELECTED ON THE SYMPTOMS YOU GIVE US.
If we are to make a successful prescription, we
must know all the details of your sickness. We must
also understand all the features that belong to
you as an individual. This includes your reactions
to various factors, your past and family history
and your mental make up.
This information enables us to selection the remedy
that removes your sickness. The medicine also makes
you well as a whole person.
In order to find out all about you, we shall be
asking you many questions. Each one of these questions
has a definite meaning and significance for us.
There is not a single questions that is useless.
Even something that your may think is not connected
with your trouble, may be the most important factor
in deciding the correct homoeopathic medicine. That
is why you must be free and frank and give us the
fullest possible information on each point. Please
read each question carefully, think and if necessary,
consult someone close to you and then answer completely.
Do not keep anything back. Remember, whatever you
tell us will remain absolutely confidential.
THIS QUESTIONNAIRE FORM HAS 8 PARTS :
- About your past illnesses and
family illnesses. Please take time to answer
this part with the help of your family members
before coming to us.
- History of your present illness.
- About all the parts of your
body.
- Deals with the factors that
affect your health.. Please think carefully
about each of the factors mentioned and write
what specific effects they have on you.
- About your mental state and
your emotional nature. Please write in this
part about your situation in life and about
all the things that are bothering you. Be totally
frank and open
- About your sleep and dreams.
- For children or you as a child.
- In this part you are given
instructions on how to report each of your complaints.
Read the instructions first. Then make a list
of your complaints and describe each of them
according to the instructions.
Download Case Record Form (English)
Download
Patient Fragment (German)
Download Questionario (Portuguese)
Download
Case Record Form (Bulgarian)
Download
Case Record Form (French)
Click on above link to download the case record
form. You can then print it, fill it up and mail
it to us.
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