Adult Patient Case Record Form

You can download the adult patient case record from offline from Clicking here.

Name *

First

Last

Date of Birth

Age

Height (in Foot)

Weight (in KGs)

Gender

Name of Father

Name of Mother

Addresss

Nationality

Phone (Residence)

Phone (Father)

Phone (Mother)

Email (Father) *

Email (Mother) *

We require the following details about your child’s symptoms. What are the complaints?

Since when is the child having these complaints?

Location: Please give the exact location of sensation, pain or eruption. Also describe where the pain or sensation spreads.

Origin of cause: Can you trace the origin of the present illness to any particular circumstance, accident, illness, incident or mental upset? (e.g. Shock, worry, errors in diet, overexposure to cold, heat etc.)

What are the factors that influence your child’s health? e.g. weather, food, pressure, anxiety etc. or any other (Please refer to part 4 on page 15 and 16 for a detailed list of the factors)

Please mention how each factor affects the child whether it increases or decreases his/her complaint, and also how much does it affect child’s complaint. (e.g. headache worse by even little exposure to sun, headache better by pressing the head)

Details of past illness of your child

Family History (To be filled by the parents only)

Father

Mother

Grandparents (Maternal and Paternal)

List of Major Diseases: Anaemia, Cancer, Diabetes, Insanity, Rheumatism, T.B., Pleurisy, Leprosy, Epilepsy, Fits, Bleeding tendency, Urticaria, Eczema, Asthma, Paralysis, Hypertension, Heart trouble, Kidney disease, Liver disease

Were there any other problems in growth & development of the child?

In order to understand the emotional and intellectual nature of the child, we will be asking certain questions. Answer them freely, carefully and completely. This information will help us much in giving the correct remedy. Also such a remedy will help improve mental make up of the child.

How would you describe the childs nature and personality in general –

How would you differentiate the nature compared to others

What is the effect of main complaint and associated complaints on the child?

Describe the unusual sensation they experience during stressful situations like nightmares, fears, before exam, with any incident.

What are his/her fears (existing and/or imaginary)?

Any incident which had a deep impact on him/her? Describe in detail.

What are the stories/fairytales that he/she likes to read/listen to?

What are his/her imaginations/fantasies? Describe in detail.

What dreams does the child get or had?

What are the nightmares that he/she gets or had?

What are his/her interests and hobbies?

Describe about the specific toys, games/specific TV serials, cartoon characters, movies the child likes

How is he/she at sports and other activities?

Describe about the drawing and coloring he/she likes

What are the other activities the child likes to do?

Describe all the qualities of your child, which makes him/her different from other children, which is unique to him/her

What does he/she wants to become when he/she is grown up and why? What are his/her ambitions?

Whom does he/she idealize and why? What is about him that he/she admires the most?

How is his/her behavior with parents, teachers, friend relatives? What are the qualities he/she admires in them?

How is his/her behavior in school and what is his/her teacher’s opinion about the child?

What kind of questions does he/she asks to parents, relatives and teachers?

What are his/her views about the city, state, country and world?

What makes your child cry or laugh?

What makes your child very angry and irritable?

What does the child do when he/she is alone?

What are your child’s first five wishes?

Personal History about Child

Any allergies?

Effect to Heat / cold climate?

What does he like to eat?

His favourite food item?

Taste – sweet / sour / bitter.

Any averions

Sleep position

Sweating, which part of body does child sweat more

Any other unusual things

What and when was the last vaccination done?

Habits

Mothers History During pregnancy

Was the pregnancy planned or unplanned?

Describe the circumstances around the period of conception? (Stressful if any)

What changes you have observed within you?

Tell the changes you noticed in your nature and behavior from the time you conceived till you delivered the child.

Anything unusual or peculiar phenomena you observed only during pregnancy that you think were not a part of your routine nature and that occurred with the pregnancy?

Any incident during pregnancy that had a deep impact on you? Describe your feelings, thoughts or any sensation associated with it.

What were your dreams during pregnancy (Also mention dreams around the time of conception, if any)? Did you have any unusual, recurrent dream that had a deep impact on you?

What were the thoughts, fantasies and imaginations about your child during pregnancy?

Did you have any unusual thoughts during that period?

Did you experience any unusual bodily sensation/movement during this period? Describe the whole experience.

Did you have any fear or nightmares during this period? Describe it.

Was there any change in your interests and hobbies during pregnancy?

Did you observe any change in your relationship with people during this period? What was it?

What were the changes in the likes/dislikes of any particular food during pregnancy?

Was there any change in your sensitivity to heat/cold during pregnancy?

Any change you observed in your general pattern for e.g. Appetite, Thirst, Perspiration, Sleep, Bowel movements, Urination

Sexual desire

Did you suffer from any disease during pregnancy?

Were you on any medication during pregnancy?

Please attach picture of tongue, face and nails (for child)

Click or drag files to this area to upload. You can upload up to 10 files.

You can download the adult patient case record from offline from here.

Disclaimer: All patients data is highly confidential and for doctor’s eyes only.

9324321819

[email protected]

9324321819

[email protected]