Online Consultation

To provide an effective Professional Homoeopathic Treatment, a comprehensive questionnaire has been prepared to help you describe your illness in detail. All the information that you are providing here will remain confidential as said in our Privacy , so don't feel inhibited. After the receipt of the required information your case will be processed and your treatment plan along with the prescription and necessary instructions will be sent to you. Patients are advised to purchase  medicine (s) from a Registered Homoeopathic Chemist/ Pharmacy in their locality.

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The field marked as * are required to submit the form. Please provide a working e-mail to avoid inconvienece.

Consultation Form

Name*E-mail*
Address*Telephone No.
Date of Birth*Married Single, Other,Divorced*
Children*Occupation*
Blood Group with Rh Factor*

MAIN COMPLAINTS /SYMPTOMS

Please provide full details of your present complaint. Pl do write if any of the symptoms are made worse or better under any circumstances. Please do write if your problem appeared after any particular event of your life.

Please don't use Medical diagnosis here, it is advisable that you use your own words and not medical terms. Please do not include Present Treatment Here!

MEDICAL HISTORY

Please state if any of the following apply to you?

DiabetesEczema or any skin Disease
Tendency to reoccurring throat or chest infectionsAllergy (sensitive) to any or various substances including food & pollens
AsthmaCancer
AIDSGlandular swellings (thyroid / tubercular / breast/ testicles)
WartsAlcohol or any other addiction
Depression or any other mental conditionMeasles / Chicken pox

Others

 

Family history (if any):

SKIN PROBLEMS (Present / Past)

PRESENT TREATMENT

Please state the present treatment along with detailed information about the medicines and its dose schedule.

DIAGNOSIS

Please provide the details of Diagnosis (if any).

 

Please write the Conclusion of the Clinical Reports.

MENTAL SYMPTOMS

How do youperceive yourself?

(Check all that are applicable)

Suspicious

Do you suffering from any anticipatory feelings?

Irritable

Proudly

How would you describe yourself & your character?

Laughing during talking

More worried about others

Type of Dreams (specify)

Talkative

Quiet

Sleep

Wanted to do things in hurry?

Emotions

Sad Events

Others (if any)

OTHER

Please state any other symptoms or relevant information which according to you is important!


 


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