Patient Intake Form: Part #4
HOMEOPATHIC CASE INTAKE QUESTIONNAIRE
Describe in your own words your major health problems:
Attributes for each complaint:
Time of aggravation
Over how many months/years
Modalities: heat/cold weather changes, activity/rest, position, rubbing, pressure, etc.
Evolution of complaint
When did symptoms begin?
Major events at the time
Past Medical History
Major Illnesses, Surgeries, Traumas?
Any other significant medical, mental/emotional events?
How do you describe yourself?
What's important to you in life?
How would your best friend describe you?
How do you react under stress?
What type of child were you?
· Relationship satisfactory?
· Work situation
· Support system
When answering the following questions, give examples and circumstances
Be specific, elaborate about the situation.
Explain what it was like for you.
Get at natural tendencies (e.g. r/o previous tx for anger, now suppressed)
Do you have any anxieties/fears/phobias?
Such as: heights, crowds, insects, thunderstorms, planes, health, animals, dark, closed spaces, etc.
What do you do in such situation?
Where do you feel the anxiety? (head, throat, chest, abdomen)
Are you a worrier? What do you worry about?
Are you neat or messy, e.g. compared to your friends?
Do you prefer to be with people or by yourself?
How much time do you spend each way?
Do you enjoy time alone?
How are you at parties?
What kinds of things irritate or bother you?
Who makes you angry?
How do you express it?
Now do you handle it?
Do you cry?
What makes you cry?
If you're upset, and someone consoles you, how do you handle that?
How easy is it for you to make decisions?
Are you easily hurt? (e.g. for some people, a look can hurt them, other people could care less what other people think or say)
Are you obstinate, moody, quarrelsome, or depressed?
How's your memory and concentration?
Are you delusional/hallucinatory/paranoid?
Has there been big grief in your life?
What is your partner's biggest complaint about you?
What is your biggest complaint about them?
How are your relationships with your loved ones, family, friends, and colleagues?
· How is your sleep in general?
· Do you fall asleep easily? What keeps you up?
· Do you sleep, through the night?
· What wakes you up?
· Back to sleep easily?
· What time do you wake?
· Do you drool when you sleep? How many times/wk?
· In what position do you sleep?
· Do you talk in your sleep?
· Do you grind your teeth?
· Do you snore?
· Do you sleepwalk?
· Do you have night sweats? What time? What part of your body?
· Do you sleep with the windows open?
· Do you sleep with piles of blankets?
· Do you have any recurring dream? Describe the dream. What is your mood in the dream?
· Describe any dream that you can remember.
· Do you wake refreshed? What is your mood when you awake?
· Tolerance to temp, humidity, weather changes, fog, mind, drafts, closed room, etc.?
· Best season? Changes occurring at particular seasons?
· Cold or warm blooded? First in room to be too hot/cold? Wear more/less clothes than others?
· Tightness at neck/waist? Tolerate saunas?
· Changes occurring at particular times?
· Reaction to environment: ocean, mountains, desert, etc.
· Appetite in general? Big or small?
· Any cravings/aversions? Give list: eggs, (smoked) meat, fish, spicy, ice cream. fruit, coffee. chocolate, beer, wine. sour. swam oysters, salt, has, etc.
· Foods that make you feel bad?
· Vegetarian? Why?
· Thirst: how much in a day? Sip or gulp down quickly? Cold or hot drinks? What types?
· How's your digestion?
· Constipation, diarrhea, gas, bloating, heartburn (more detail if any positives)
· Do you perspire much?
· Quantity, location (where first)?
· Unusual odor?
· PMS sx?
· Regular/irregular cycle?
· Flow heavy or scanty? Clotting? Dark or light?
· How long does it last?
· Vaginal/urethral discharge?
· Other pains?
· Sexual energy?
· Intercourse, how many times per day, week, month?
· Impotency, lack of desire?
· What is your energy like during the day?
· Best/worst times?
REVIEW OF SYSTEMS
· Dandruff, eruptions
· Infections, itching, pain
· Visual disturbances
· Hearing. History of otitis (ear infection)
· Eruptions in/around ears
· Ringing, unusual noises
· Sensitive to noise (any in particular?)
· Sense of smell, nose bleeds
· Sensitivity to smells
· Stuffiness. allergies/hay-fever
· Unusual taste, halitosis
· Prone to cavities, sores
· (Look at tongue: color, coating, fissures, indentations, etc.)
· Teeth discoloration
· Palpitations, tightness, pain, shortness of breath
· Hx asthma, bronchitis, pneumonia
· Hx UTI, urethritis, STDs, PID
· Unusual discharges
· Infections, eruptions, herpes, warts
· Aches, pains, stiffness, swelling
· Numbness, tingling, unusual sensations,
· Eruptions, warts, itching
· Bruising, wound healing ability
· Quality of hair/nails brittle or strong?
Family Health History:
· TB, CA, diabetes, cardiac, strokes, STDs, allergies, arthritis
Past Med Hx:
· Infections, dz, injuries, failure to recover (never well since)
· Meds: type, sensitivity
· Recreational drugs?
· (May be covered in emotional/mental)
· Marital status
· Work conditions
· Tobacco, Alcohol
Regional exam as necessary
Lab tests as necessary