Name:

Address:

Contact info including emaill address and Phone number:

what is problem , explain it? What is your profession ? :

when this problem started ? :

what time this problem intensify ?:

what makes your problem feel better ?:

what is your mood when your problem intensify ?:

what you like to do most during illness or when you well?:

what type of person are you ( cold or warm or hot (meaning always needing fan, staying outside or covered with blanket (coat,jacket)) ) ?:

how is your thirst ( water ) ?:

how is your appetite ? what you like to eat most ?:

how is your anger ?:

when you become very angry ?:

what you do when you very angry ?:

do you feel you are different from others ? if yes explain it.:

do you expect anything from anybody ( in reference emotion or any kind of help ) ?:

how is your sleep ? do you perspire during sleep ? In what situation you perspire ? which position you sleep ( I mean on back, on your left side or right side or on tummy etc) ? how much you wrapped with blanket thinks like that during sleep ?:

do others opinion matter to you ? If yes explain please.:

any particular likes( food, in personal, manner etc) or dislikes ?:

any fear or anxiety ?:

do you lose or gain weight easily ?:

anything you like to say and explain which might help since homeopathy works on mental and emotional level ?:

Any history of TB ? Dibetic and BP ?:

Currently taking any medicine ?:

How you react to temperature change ? or any surrounding change ? any kind of change ?:

What is your nature ? what other say about your nature ?:

How is your perspiration ? If you perspire explain.:

Any fear or worry ? any particular dream ?:

Any food/drink/tobacco disagree ?:

How you react to Sun / summer /winter?:

Any grief/ disappointment/tension with family / friends ? If yes explain.:

Any allergy ?:

Can you stand in Public and give lecture ?:

How is your bowel movement ? how is your urination ?:

How is your marriage ? can you describe your current marriage relationship ? how often you intercourse in day/week ?:

How you react to milk and egg ?:

Do you need stimulant like tea , coffee etc ? How often and it has to be cold , warm or hot ?:

What relative, friends, neighbor or colleague say about you ( in any( nature/physics etc) thing ) ?:

Do you cry ? In what situation ?:

How is your menstrual? Explain as much possible.:

Do you have any skin problem present/ past/childhood ? If yes explain. How it gone ?:


This is case submission form