Acute Case Form

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

You can also download the form in French and Portuguese

Name *

First

Last

Age

Gender

Occupation

Address

How did you know about us?

Have you used Homoeopathy before?

Briefly, describe your chief complaints? Fever/chills/cold/cough/pains/diarrhea/weakness/joint pains/breathlessness (etc.)

What is the cause of chief complaints according to you?

Emotional Cause

Physical Cause

Body part where the problem is

Describe the chief complaint and associated features in detail

Chill/heat/sweat

Which part of the body does it begin?

Which area is it felt maximum?

State your reaction to appetite, thirst, sleep, urination, bowel movements, sweat etc.?

Any particular direction of chills/heat/sweat (ascending, descending etc.)?

Cough/asthma/respiration

Any strong aggravating factors for the above complaints?

Any strong ameliorating factors for the above complaints?

Loose/dry cough/with pain/without pain etc.?

Taste of cough in mouth?

Posture – that makes the complaint worse/better?

Details of chief complaints

What are conditions of aggravation and amelioration?

Time: when is it more

Temperature: Reaction to cold and warm

Posture: worse or better by Lying on back, Lying on abdomen, Lying on side etc.

Reaction to open air/weather

Thirst (changes in pattern)

Taste (changes in pattern)

Reaction to eating

Reaction to sleep (changes in pattern)

Investigations

Please upload picture of face and tongue *

Click or drag files to this area to upload. You can upload up to 2 files.

Changes at general level (any change from normal)

Thirst (quantity/frequency etc.)

Sleep (position/quality-restless/deep etc.)

Reaction to heat and cold (any changes)

Stools (diarrhea, constipation etc.)

Urination (↑ or ↓, painful, smell etc.)

Appetite (hunger ↑ or ↓ etc.)

Cravings for any particular food/drink

Aversion to any particular food/drink

Changes in state of mind

What is the reaction to disease?

Reaction to company and being alone?

State of mind with respect to time of the day- morning/afternoon/evening/night

Fears/anxieties

Any other thoughts/feelings

Dreams

Facial expression

Dullness/activeness (level)

Changes in state of mind since symptoms started

Any other changes or observations

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

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

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