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Homeo Foundation

A HOUSE FOR COMPLETE TREATMENT SOLUTION FOR CHRONIC DISEASES

Online Treatment :

Sorry we are not entertaining any online treatment of patients as this point of time delivery of medicines is not undertaken by any Courier Service provider. Fill the form only if any one can pick the medicine on your behalf from either of our Center at Patna/Noida.

If unable to visit us then kindly take time to fill in this form with care.

Please fill the questionnaire in detail. Things that you might feel “medically not relevant” like your habits, pattern of behaviors, likes and dislike, moods, strange feeling and sensations etc, may play important role in medicine selection. Report your individual inclination to the illness, particular changes that you noticed recently in appetite, in like or dislike for particular foods, in behaviors, in sleep patterns, in bowel habits, dreams etc.

Note : This Form will be reviewed only after receiving fee for Consultation. 

In case you are not able to fill this form, please Download form from here and send it to our email id : homeofoundation@gmail.com

Fill the online form or send it via email. >> Deposit the consultation fees as asked. >> Receive your medicine prescription.

Name*

Age* :

Sex* :

Contact No* :

Email Id :

Address :

Please write a brief of your Present Problems and information’s about how long you have had them (in chronological order).

Present Problems :

Family History : Please tell about diseases of paternal and maternal grandparents. It helps in selection of medicine for diseases like Allergies, skin problems, asthma, migraines, diabetes, mental disorder or any other neurological disorders, heart problems etc. For example" Elder sister has/had eczema, paternal aunt died because of complications of heart disorders, maternal grandma had diabetes," etc.

Family History :

Childhood history : (As far you can remember) whether your delivery was normal or Caesarian, whether there is a history of Neonatal jaundice, Measles, Mumps, and Typhoid etc. Side effects of vaccination like fevers, loose bowels, running nose, coughs etc.

Childhood history :

GENERAL INFORMATION

a) How is your appetite ?

b) Is there a tendency to indulge in particular kinds of foods (ex. sweets /sour/salty foods) ?

c) Do you have allergic or sensitive to any foods ?

d) What kind of weather are you most comfortable in? (Summer/humid/ Winter) ?

e) Are you particularly uncomfortable in any weather or climate? If Yes Please write ?

f) Do you sweat at all? If you do, where do you sweat noticeably? (Scalp/upper lip/under arms/back/chest) ?

g) Under what circumstance you sweat. (During eating/under tension/ after physically exhort) ?

h) Are you feel more comfortable the open air or in closed rooms ?

i) Do you dream? If yes, do you remember them? What is content in general? (eg: daily events falling into space, running after train, etc.)

j) Quality of sleep? (Feeling refreshed after sleep or tired, laziness etc) ?
ans :-

k) Tell something about your regular/daily habits (regular constipated/diarrhoea) 1. Is it modified by anxiety? By diet ( eg: food cause diarrhea) ?

l) How is your liquid intake? (Feel thirsty all the time/fairly normal) ?

m) How would you describe yourself?(Admirable/social/attendance to be picky about things like cleanliness and keeping appointment etc.) ?

n) How do you react to stress/tension? (Tend to be verbally expressive/to keep things to yourself and broad about them, etc.) ?

o) Additional Information (If any) ?

Additional Questions For Female Patients

a) Age at onset of Periods ?

b) Periods? (regular / Irregular) ?

c) Physical symptoms preceding the onset of periods (eg: heaviness /pain in the breasts , changes in moods/ appetite/bowel habit, backache, Pain in the legs, Headaches, dreams etc) ?

d) Duration and interval between periods (eg: bleeding last for 3-5 days and the interval between period is 27 days ?

e) Are you using any contraceptive pills ?

f) Any discharge before / during / after periods ?

g) Number of children and whether they delivered normal? Any post-delievery problems ?

h) Were the children breast fed or not?Any problems during the breastfeeding phase ?

i) Any abortions ?

j) Does the periods cease gradually or abruptly ?

k) Have you had any operation done in the pelvic area ?