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    Please provide us all the appropriate details in the form below.

    All the fields marked with (*) are mandatory and cannot be left unattended

    Reply with NA (NOT APPLICABLE) for the questions which are irrelevant.

  2. * I need treatment for:


    * Age:


    * Name:

    * Occupation:

    * Email:

    * Mobile / Phone:

    * Address 1:

    Address 2 :

    * City :

    * State / Province:

    * Pincode / Zip:

    * Country :


  5. * Chief Complaint:

    Mention in detail about the Onset, exact Location of the Complaints, Sensation, Modalities (Better/Worse with regards to Time, Position, Relation to heat and cold, Season). Your mental state with regards to Family, Work, Emotions (Anger, Fears) – just before the onset of disease and few weeks prior to it

  6. * Duration & History of Present Complaints:
  7. * Family History:

    Mention about the diseases of your Parents, Siblings. Maternal & Paternal – Grand-parents, Uncle, Aunt, Cousins

  8. * History of Past Illnesses:

    Mention about the diseases you have suffered from – since childhood until recent past, in
    chronological order. Hospitalization & History of Blood transfusion, if any. Regular intake of specific Medicines – Tonics, Sleeping pills, Purgatives etc.

  9. * Personal History:

    Mention about Habits (Daily routine and Work related)

  10. Vaccinations

    Mention the vaccine and specific age. Have you suffered from any reaction?

  11. Sexual Relations:

    History of sexual relationship with spouse/ other than spouse – Before/ After marriage. History of masturbation

  12. * Urine & Stools:

    Quantity, Frequency & associated complaints, if any

  13. * Skin:

    History of skin disease and specific treatment. What is your skin type - Dry/ Oily? Do you have warts, moles or birthmarks on any part of the body?

  14. * Appetite:

    How many times do you eat, what and when?

  15. * Desire, Aversion, Disagree:

    Preference, Dislike, Disagree of Food/ Drinks/ Fruits/ Sweets/ Edibles – Taste, Preparation, Temperature – Hot/ Cold. Mention history of any abnormal desire for Ash, Earth, Lime etc, with age.

  16. * Thirst:

    How many glasses of water do you drink in a day? Do you drink an entire glass/ half a glass/ sip water? Do you prefer Hot/ Cold water to drink?

  17. * Thermals:

    Your Likes, Dislikes & Reactions to the Seasons – Tolerance/ Intolerance to heat, cold, rains, humid weather etc. Do you prefer the open air? What is the type of clothing you like for regular use? How would you like to bathe – Hot/ Cold water, in what season? Which season, climate and weather your body cannot tolerate? Do you require any covering while sleeping?

  18. * Sleep:

    Write in detail about the position during sleep. Do you perspire during sleep? If yes, in which part is it more. Does it stain? Does your mouth remain open? Does saliva dribble? Do the eyes remain half open? Snoring?

  19. * Dreams:

    Do you have any specific dreams? If yes, mention the details and the frequency of the same.

  20. * Perspiration:

    What is the amount of sweat (Scanty/ Moderate/ Profuse)? Is it more on any particular part of the body? Does it stain? Do you feel Better/ Worse after perspiring? Any peculiar odour?

  21. * Life Space:

    Please write a short synopsis (Summary) about you as a person along with details of your family background, school & college education, business or job satisfaction etc. Emphasize any such event in your life, which you feel has any relation to that of the evolution of your present state of illness. Mention about your Attitude, Fears, Ambitions, Behaviour, Emotions etc. Explain in detail with relevant examples.


  23. * History of Menstrual Cycle:
  24. * Age of Menarche:
  25. * Regularity/ Frequency of the Cycles:
  26. * Duration, Quantity, Nature of discharge:
  27. * Symptoms before, during and after menses:
  28. * Leucorrhoea or any other abnormal discharge, if any:
  29. * Last Menstrual Period:

  31. * Number of children with age:
  32. * Type of delivery with complications, if any:
  33. * History of abortions, if any (Natural/ Induced):
  34. * Undergone surgery for family planning?:
  35. * If not, methods adopted for family planning:
DISCLAIMER:The information provided should be examined in the light of individual case evaluation by the doctor reading it. The website developers, GraceHealing Homoeopathy centers and Dr. Abdequaem MH Chimthanawala’s team of doctors take no responsibility whatsoever of the consequences experienced by the patients who may use the information provided on this website. Read More
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