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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?

	Diabetes		Eczema or any skin Disease
	Tendency to reoccurring throat or chest infections		Allergy (sensitive) to any or various substances including food & pollens
	Asthma		Cancer
	AIDS		Glandular swellings (thyroid / tubercular / breast/ testicles)
	Warts		Alcohol or any other addiction
	Depression or any other mental condition		Measles / 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	Do you suffering from any anticipatory feelings?
	Proudly	How would you describe yourself & your character?
	Laughing during talking	How would you describe yourself & your character?
	More worried about others	Type of Dreams (specify)
	Talkative	Type of Dreams (specify)
	Quiet	Sleep
	Wanted to do things in hurry?	Sleep
Emotions		Sad Events
Others (if any)

OTHER

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