Dr. Pradosh Kumar Das M.B.B.S.,M.B.E.H.
Clinic : PRANAB HOMOEO CLINIC, ST.JOSEPH ROAD, RANJHI,
JABALPUR. (MADHYA PRADESH) INDIA PIN – 482005.
Mobile No. : 9827517030 & 8109719163 • Medical Emergency. : 8827398387 Res. : 9301957972
My Websites :-
My Email ID :-
Instructions to fill in the Case Record Form
Homeopathy is a holistic science based on concept of individualization. In order to find out accurate
homeopathic medicine, it is essential to understand not only your complaints but also your entire
personality, your emotional state, your stresses, your relationships as well as effects, likes and dislikes
pertaining to food climate etc.
Incomplete information will make correct choice difficult. You are therefore requested to supply the
Information without keeping anything back as irrelevant or of little importance. The history that you provide
Becomes basis for further inquiry. Present photograph or a Video may be attached to understand the present condition of the patient. Hence, we earnestly request for your full co-operation. All information
Supplied, of course, will be strictly confidential.
This information will help us in rendering you the best possible service.
CASE RECORD PERFORMA
CASE REFERENCE NO. : DATE :..................
FATHER’S /HUSBAND’S MOTHER’S NAME
AGE SEX M/F PRESENT WT. _____ Kgs. & HT. _______ Cms.
NATIONALITY MARITAL STATUS.: Single / married / widow / widower / divorced
PROFESSION / OCCUPATION :
TELEPHONE/S FAX NO.:
PRESENT COMPLAINTS (MAIN COMPLAINTS):
ONSET : ORIGIN OR CAUSE OF EACH COMPLAINT:
PAST HISTORY (PREVIOUS DISEASES AND THEIR TREATMENT)
FAMILY HISTORY (Give in detail if any of your blood -relatives i.e. parents, grandparents, siblings, aunts
and uncles are suffering or have suffered from the following ):
Coronary artery disease, Angina etc.
Gonorrhea/syphilis or STD
Psychiatric & Mental Disorders
Any other sickness not mentioned above ?
Kindly elaborate and mention habits, addiction like alcohol, smoking, tobacco etc.
veg / non-veg / eggs/
Cravings & Aversions in food :
Mention grades of cravings as per intensity of craving / aversion +,++ or +++ and aversions -,--or ---
for example if you love sweets, mention +or ++ or +++, if you dislike mention - or --or ---
Do you add Extra salt in your food ?
Sour things /pickles
Seasoned and spicy
Fried and fats
Any other cravings in food ?
How is your Digestion ?
Any complaints after eating ? For example... Fullness of abdomen, Gas formation or Diarrhoea after eating
Do you feel bloated, full and heavy after eating?
Can you remain hungry for hours on end without food ?
Do you get irritable with hunger?
Does any item of food causes any discomfort eg. Acidity headache, flatulence etc.
How is you thirst ? please mention the grade of thirst if you are very thirst, You may mention grades+ + or
How much water do you take at a time ?
How many times per day?
Your preference in drinks : please mention the degree of craving+,++or +++ would you prefer cold
/chilled water or drinks even in the height of winter would you like your cup of tea /or coffee piping hot or
just normal warm how many cups fo tea / coffee do you generally take in a day Any aversion to any drinks?
State how you are affected by or how you react to the following :-
1. Cold in general, cold air, drafts, cold winds etc .
2. Do you like to cover your head (or wear a cap) when you go out in the cold or when exposed to draft
of cold air?
3. Warmth in general, warmth of bed or of room, external warmth like hot fomentation etc.
4. Weather. Dry, cold wet, Rains, Cloudy etc.
6. Open fresh air likes/dislikes
7. Near the sea /on mountains
8. Eating and drinking (before, during and after)
10. Any particular item of food /drinks which adversely affect you or make you sick
11. Closed. crowded places, elevators /lifts etc.
12. Exertion or physical strain, mental strain
13. Lack of sleep
14 . In what part of 24 hours do you feel the best or the worst
15. Do your troubles tend to occur or become worse, periodically (eg. daily or alternate days, every
week, yearly, during new or full moon etc.)
STOOL /BOWEL MOVEMENTS
Do you regularly have a satisfactory bowel evacuation?
How many times do you move the bowels? when?
□ well formed
□ semi- formed
□ very hard
□ loose Odour
colour of stool any straining required or stool even though stool might not be hard or constipated?
Any urgency for stools (eg. do you have to run for stool first thing in the morning or immediately after
Any pain burning bleeding with stool Piles /fissure /fistula ?
Do you have flatus (wind) when passing stool and is the stool noisy and spluttering?
Frequency , day and night
Any burning during urination?
Any smell (odour) in the urine?
Any difficulty in passage of urine?
Any difficulty in retaining urine ? Do you have any incontinence while coughing or sneezing ? Is the urine
very urgent and you must rush immediately or it will escape ?
Any associated complaints with urination ?
FOR MEN - Any sexual disturbance ?
Excessive desire or aversion to sex
Disability of performance, premature ejaculation etc.
Any history of sexual abuse, excessive masturbation etc.
Any complaints after intercourse ? Weakness after intercourse, Backache after intercourse
FOR WOMEN - Any sexual disturbance ?
Excessive desire / aversion to coitus ?
Any leucorrhoeal discharge ? Itching, burning or discomfort associated ?
Any sense of 'bearing down' at the time of menses ?
PREGNANCIES: How many times have you been pregnant ?
How many children do you have and their age ?
Did you have smooth pregnancies ?
Did you take any medication during pregnancy ?
Did you have normal deliveries ?
MENSES : Age of appearance of first period (Menarche)
How are the periods ? (regular or irregular)
What is the duration of your period and how many days cycle ?
How is the flow ? - (scanty, heavy, clotted, any odour, colour)
Any PMT (Pre-menstrual tension)? Do you have any complaints associated with, before or after menses ?
Eg. Moods changes, Headache, Irritability, Anger, Weeping, Depression, Diarrhoea or Constipation
Any changes in your skin around menses ?
Any heaviness or pain in breasts before menses ? Any nodules in the breast ?
Age of menopause
Any associated complaints at the time of menopause eg. Hot flushes, coldness Palpitation, Anxiety,
PERSPIRATION (SWEAT) :
Do you perspire a lot ?
Any particular part of the body that you perspire more on ?
Any strong / offensive odour associated (eg. Sour smell) with the sweat?
Does the perspiration stain the clothes ? eg. yellow stain on clothes
Do you sleep well ?
Any particular posture in which you lie the most when you sleep ? eg. Lying on the sides (right or left) back
or on your abdomen, curled up etc.
Do you feel refreshed after sleep ?
Do you dream while sleeping ?
Any particular dream that is recalled and often repeated ? (eg. Frightening dreams of falling from a height or
being pursued by some men, or dead people or relatives water, religious, temples etc. )
Does any of your complaints get worse or better before, during or after sleep ? eg. Cough or asthma attack
that wakes you up at night or migraine or waking in the morning. Hot flushes just as you begin to fall asleep.
Any skin problems that you have or had earlier (eg. Allergies, eczema, fungal infections, pigmentations,
Any itching or discoloration associated with it ?
Any factors which worsen the skin problem ? eg. Any item in food, any weather conditions or washing with
warm or cold water.
Any treatment taken for it and its details ?
Any complaints or abnormality of Nails or the skin around nails ?
Any complaints of Hair falling, early graying, dandruff, thinning etc. ?
Any warts, moles, birth marks on the body ?
Does your skin heal normally after an injury or takes very long to heal ?
Any tendency to form excessive scar tissue (Keloids) ?
Any tendency for wounds to suppurate (form pus easly) ?
Are you applying any local ointment or cream on body?
THE MIND :
(It is very important to give as much details as possible in this the Performa especially in chronic diseases)
Have you noticed any marked changes in your mental state lately? If so, describes It in detail please. Have you
become or are.
1. Anxious /afraid of anything eg. Being alone , animals, darkness ,disease ,thieves ,robbers, sudden noises,
2. Do you get startled easily by sudden noises, telephone bells, banging of doors etc.
3. Suspicious, doubting
4. Impatient or hurried and hasty do you eat hurriedly and there is always a sense of hurry?
5. Offended easily (cannot take any criticism)
6. Are you critical of others, always finding faults
7. Irritable, quarrelsome, violent etc .
8. Depressed easily, sad, gloomy
9. Timid /shy/bashful / embrassment
10. Jealous or suspicious
11. Anxious, restless, nervous or excitable
12. Do you fell very anxious and apprehensive before examination, before stressful situations, public
13. Are you silent, quiet, reserved or talkative? Do you make friends easily?
14. Are you very affectionate? Do you demand love and warmth from others?
15. Do you cry easily? What makes you cry (grief of others, music kind words .of affection etc.)
15. Are you very sympathetic in general and go out of
your way to help people in need? Are you easily moved to tears at the plight of
16. If someone consoles you when you are upset, does it help or does sympathy towards you makes the
17. How do stand and react to contradictions ?
18. Are you an authoritative person, always in command and giving orders and expecting them to be
followed by everyone around you ?
19. Any imaginary fears or feelings ? (eg .that someone might want to harm you or hurt you and that
people are against you?)
20. How is your memory, power of concentration and mental ability ?
21 Do you fell humiliated or hurt easily? Would this give rise to any physical complaints?
22. Are you over conscientious about details, cleanliness, tidiness, punctuality etc.? are you a
perfectionist by nature , being menticulous , fastidious and even fincky?
23. what is the greatest grief that you have felt in life ?also what are the greatest joys in life you have
24. Can you mentally relax easily ? for instance, can you switch your miad off work ,problems, children
etc.? do you enjoy vacation? And can you totally relax when on a holiday or do thoughts of work or
what is happening at home keeps bothering you etc.
25 At work or with colleagues, subordinates or your boss or seniors how do you equate with them?
Would reprimand or scolding from them upset you tremendously? if so how?
PREVIOUS TREATMENT TAKEN
Disease Medicine prescribed System of therapeutics
X-RAY SCANS, MRI etc. others
In case if you have any queries feel free to contact us at : Tel. :9827517030 • 8109719163 • 8827398387