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KRISHNA HOMOEO CLINIC#MIG-26, SHREENIDHI COMPLEXABOVE HOYSALA DARSHINI, OPPOSITE SHOPPERS CHOICEHOYSALA CIRCLE, KENGERI UPANAGAR, BANGALORE-560060?CASE NUMBER-Name:Age:Gender:Weight: Height:Marital Status:? Religion:Address:Contact number:??Family medical history:?Past history of health:?Have you been hospitalized? ?When?-Where?-??Have you taken medications in the past? If so,?which medications have you taken?-??What was your?response to the medication??-??Vaccination-?Do you have any allergies?-?General Symptoms?Are you?presently taking medications??If so,? which medications are you taking??Chief complaint????When did?it first occur???What's your?symptom????Describe the?sensation experienced.??Give the precise location.??List any concomitant symptoms.??Modalities?When do?your symptoms get worse?-?(morning __ evening __ night __ during sleep __ on rising __ before a thunderstorm __ after a thunderstorm __ in damp weather __ in cold weather __ wearing tight clothes __ in a warm room __ while washing oneself ?__ in bed __ while moving around __?during rest __ in a closed room __ in crowded places __ in the winter __ in the summer __ in the spring __ in the autumn __ at the sea __ in the sunlight __ lying on?ones back __ lying on affected side __ while exercising __ while talking __ when the temperature changes __? at the smell of tobacco __ on missing a meal __ on the onset of a menstruation __ in cold, wet weather __ in bed __)?When do your symptoms get better?-?(bend backwards __ doubled over __ upon moving __ resting __with cold applications __ warm applications __ in the morning __ in the evening __ in the night __? listening to music __ applying pressure __? uncovering the feet in bed __ during the summer__ at the sea __ outdoors __ opening a window __ left alone __ while eating __ on the onset of a menstruation __)??How's your appetite?-?(good?__ decreased?__ never hungry__?always hungry __ capricious eater__? can't finish a meal __ hungry soon after a meal __)?List any eating disorder ____________?What do you?have an aversion?to?-?(food ___ water___ meat ___ bread__ fish__ shellfish?__ butter__ eggs ___ fruits__ milk__ onions __ pickles ___ wine ___vegetables ___ cabbage __ beans __ pork __ potato ___ soup __ ice cream __? cold food __ warm food __ sour?food __ sweets __??)??What or who do you dislike?-?(a family member?__ husband __ wife __? strangers __ company __ friends __ music ___ noise __ sun__ light __ odors __ exercise __?being indoor __ closed windows __ tight clothes __ being contradicted __ being consoled __ mental work __ writing __ being wrong __ bathing __)?What do you have a strong desire for?-?(alcohol __ coffee __?milk __ bread __ butter__ cheese__?meat __? eggs __ chocolate __ lemon__ pickles __ potato __ sweet foods?__ ice cream __ cheese __ pastry __ salty food?__ fatty food __?sour?food __ bitter?food __ fish __ oysters __ beer__ wine __ tea __?pop __ fruits __ vegetables __ hot foods __ spicy foods __?cold foods __ room temperature foods __?)??What do you thirst for?-?(large quantities of water __ small quantities of water __ hot drinks __ cold drinks __ room temperature drinks __ ice cold water __ coffee __)?What do you have an addiction?to?-?(alcohol __ cigarettes/tobacco __ sex __ coffee __ chocolate __ narcotics __ illegal drugs __ sedatives __ diet pills __)?Emotional Symptoms??(mania __? emotional instability __ hallucination?__?confusion __ depression __ poor memory __ poor concentration __?learning disability __ suicidal tendencies??__? anger __?broken heart?__ anxious ___ repulsion for sex __ desire for attention ___ aversion to mental work __ aversion to company __ aversion to children __)??What do you fear most??(enclosed spaces___ failure __ affection __ contradiction ___ others opinion ___ being touched __ heights __ crowds __ snakes ___ the dark __ driving __ death __ illness __ burglars __ thunderstorms __ being alone __)???How would you describe your sleep??(normal __ deep __ disturbed __ restless __ interrupted __ short __ night terrors??__? sleep walk __ sleep apnea ___? insomnia __?bad mood on rising ___ avoid sleeping on the right side of the bed __ avoid sleeping on the left side of the bed __)?Do you have a recurring dream? ___?Describe your dream: __________________?Sexual symptoms:?(excessive sexual appetite?__?premature ejaculation __ pain during sexual activity __ problems with orgasm __ impotence __ infertility __ vaginal dryness __ sexual dysfunction __ difficult coition __ replusion for sex __??sexually dissatisfied __?painful erections __)?Physical Symptoms?What's?your?body shape?-?(normal??__?slender __ chubby __ overweight __ underweight??__ tall stature??__?short stature __ medium stature __ thin arms __ flabby upper arms __ thin legs __ flabby thighs __ broad shoulders __ wide hips __ narrow shoulders?__?narrow hips___ flat abdomen __ big butt __?hourglass shaped body __ pear shaped body ___)??What's your face shape?-?(oval __ square __ round __ heart shape __ diamond shape __ high forehead __ receding chin __ square jaw?__?big cheeks?__)??What's?the colour of your skin??white?__?pink?__?olive?__?brown?__???What's?your facial expression??happy __ sad __ fierce__ cold __ tired __ angry __ suspicious __ smiling __ proud __ frightened ___??What condition is your skin??(healthy looking __ unhealthy looking __ dry __ oily __ combination __ acne __ flushed__ shallow__ liver spots __ freckled __ porcelain skin __ goose flesh skin?__ rashes __ discoloration __ excessive sweating __ dirty looking __ moles __ itchy__?bruises __ warts __ hives __ cysts __ boils __ skin infections __)???Eye symptoms:?(dry __ itchy __ burning __ discharges __ pain __ watery __ sunken __ contracted pupils __ strabismus __ blurred vision __ diplopia __ myopia __ tunnel vision __ photophobia __ swollen lids?__?long eye lashes __ dark circles under the eyes __ tears __ styes __ sensitive __ redness __)??Ear symptoms:?(impaired hearing __ eruption behind ear __ itching in __ noises in? __ fluids in?__ inflammation in __ discharge from ears __ recurring?ear infection __ pain left __ pain right __ pain behind __ ulceration in front of ear __ ringing in the ears __ hearing loss __)??Nose symptoms:?(long __ crocked __ cold tip __ red tip __ brown saddle on the bridge __ dry nostrils __ discharge right nostril __ discharge left nostril __ epitaxis __ stuffed nose?__ dry catarrh __ congestion of blood __ obstruction of the airways__ polyps __ sensitive to odors __ ulcers __ difficulty breathing __ loss of smell __ sinus infection __ post-nasal drip __)??Mouth symptoms:?(dry mouth?__ drooling __ bad breath __ oral thrash __ canker sore __ excessive salivation __ discoloration of the tongue __ protruding tongue?__?ulcer?__?bitter taste __ speech difficulty __)??Lips symptoms:?(dry __ cracked?__?chapped __ swollen __ herpes __)?Teeth symptoms:?(asymmetric __ long __ short __ rectangular __ loose __ sensitive __? grinding?__ numerous caries __ missing teeth __ bleeding gum?__? gum abscess __ pain chewing __ pain?drinking something cold __ black teeth __ green teeth __ yellow teeth __)??Internal throat symptoms:?(dry __ inflamed __ sore __ sensation of a lump __ excessive mucus __ narrow sensation __ choking sensation?__?swallowing difficulty __ pain swallowing __ hoarseness __ loss of voice __ throat infection __)??External throat symptoms:?(induration of glands __ lump in the throat __ goitre __?pain of the thyroid gland __)??Respiratory symptoms:?wheezing __ accelerated breathing?__ difficult breathing __ deep breathing?__ asthmatic __ shortness of breath __?obstructed respiration??__?weak respiration __ gasping for air __ irregular respiration __ slow respiration?__?loud __ rattling __ whistling __?asphyxia __?frequent respiratory infections __ bloody sputum __? yellow catarrh __ persistent cough __??Digestive symptoms:?cramps __ bloated __ heartburn __ feeling of emptiness __ fullness __ heaviness?__ indigestion after a meal __ cutting pain __?gnawing pain __ rumbling __ colic __ flatulence __?stomach ulcer __ hiatal hernia __ anorexia __ bulimia __??Cardiovascular symptoms:??heart palpitations __ fluttering sensation __ constriction of the heart __ dilation of the heart __ chest pain __??Stools?regular __ frequent __ hard __ large __ scanty __ soft __ dry __ watery __ bloody stools __ loose __ copious __ greasy __ frothy __?bilious __ fetid __ odorless __ colic before a stool __ an urge without success __ slimy mucous in stool?__ involuntary stool __ painful stool __ diarrhea __ constipation _??Shape of stool??s?shape __ flat?__? narrow __?chopped __?pasty __ balls like sheep?dung?__??Colour of stool?brown __?green __ grey __ black __ yellow __ white __?ash __ bluish __?orange __??Bladder symptoms:???weak __? painful __ obstructed __ calculi __? infection __ retention of urine?__? sensation of fullness __?paralysis __??Urological symptoms:?frequent urination __ albuminous __ acrid __ alkaline __ bloody __ burning __ increased __ scanty __ involuntary __ urging __ dribbling __ interrupted __ retarded __ bloody urine __ painful urination __ urine comes out in drops __??cloudy __ greyish __ saffron colour __ watery __ prostate problems __??Arthritic Pain:?Where do you?feel the pain??hand _ finger _ wrist _ shoulder _ thumb?_?hip?_?leg _ calf _ ankle _ foot?_?toes?_?Where?do you feel stiff??shoulder??__?hand?__?finger ___ hip?__?knee __ ankle??__?Where?do you?get swollen??hand?__?wrist?__?fingers __ knees __ legs __ ankles?__?toes __?Eczema & Psoriasis:?Where do you have eczema???face??__?behind the ear __ inside the ear __ neck __ finger??__?hand __ arm __ leg __ foot __ genitals __ anus?__?Where do you have psoriasis??in the elbow crease??__?in the knee crease __ behind the elbow __ on the knee?__?Where do you have?dry itchy skin??hands ___ feet ___ knees __ elbows __ scalp __ face __??Describe your menses:?early __ late __ normal __?irregular __ scant __?heavy __ painful __ long duration __ short duration __ dysmenorrhea __ metorrhagia __ blood clots __ get?headaches during menstruation __? 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