Natures Way

Dr. Sahni's Homoeopathy Clinic.com





Pioneer in alternative medicine & health care!

Consultation Form

All the information that you will be providing here remains confidential as said in our Privacy Policy.

Note: Kindly make sure that the email-id is functional. Please do not use this form to submit progress report. Reply to the email address at which you received your treatment plan.

Special Characters are not allowed in the forms. Only Underscore, dash, comma & full stop are allowed!

( * = Mandatory)


Name * E-mail *
Address Telephone No.
Date of Birth * Sex *
Occupation * Blood Group *
Marital Status * Children

Personal History


Childhood Illness: (Check all that apply)

Measles Mumps Chicken Pox Rheumatic Fever Rubella

Immunizations: (Check all that apply)

Tetanus Hepatitis BCG Chicken Pox MMR Poilio

Have You Ever Had Following: (Check all that apply)

Arthritis Cancer Diabetes Depression Dizziness Epilepsy
Hepatitis/jaundice Herpes High Blood Pressure Eczema Sore throat Frequent Venereal Disease

Medical History


(Check all that apply)

Asthma Chronic Bronchitis
Allergy (sensitive) to any or various substances including food & pollens Tuberculosis (TB)
Sinusitis Warts
Glandular swellings (thyroid / tubercular / testicles) Migraine/Headaches
Alcohol or any other addiction Back or Neck Pain, Stiffness, Soreness

Family History


(Check all that apply)
Blood Disease/Clots Father Mother Sibling Grand Parents
Cancer Father Mother Sibling Grand Parents
Diabetes Father Mother Sibling Grand Parents
Epilepsy Father Mother Sibling Grand Parents
Heart Disease Father Mother Sibling Grand Parents
High Blood Pressure Father Mother Sibling Grand Parents
High Cholesterol Father Mother Sibling Grand Parents
Triglycerids Father Mother Sibling Grand Parents
Mental Illness Father Mother Sibling Grand Parents
Stroke Father Mother Sibling Grand Parents
Thyroid Disease Father Mother Sibling Grand Parents
Tuberculosis Father Mother Sibling Grand Parents
Any other Family history:

Specify Your Main Complaints/Symptoms *


Please don't use Medical diagnosis/present treatment here; it is advisable that you use your own words and not medical terms. Describe if any of the symptoms are made worse or better under any circumstances or the problem appeared after any particular event of your life.

Mental Symptoms


(Check all that apply)

Suspicious Irritable  Feel Stressed/Tired Laughing during talking 
More worried about others Talkative Quiet Wanted to do things in hurry?

Do you suffering from any anticipatory feelings? (Specify)

How would you describe yourself & your character?

Type of Dreams (specify)

Sleep (specify e.g. Troubled/Sound etc.)

Emotions (specify)

Sad Events (if any)

Skin Problems (Present / Past) (Specify)


Gynecologic History


Are your periods regular? 

Yes No

Have you gone through menopause?

YesNo

Breast Heaviness/Pain before Menses? 

Yes No

Obstetric History


No of Pregnancies? No of Miscarriages?
No of Abortions?    

Present Treatment


State present treatment with detailed information regarding medicines and its dose plus any herbal or vitamin supplements that you might be taking.

Diagnosis


Provide details of Diagnosis (if any). Write the Conclusion of the Clinical Reports (if any).

Updated on: 23 May 2010