SECTION 1: Patient Information
Full Name (Short Answer)
Age (Short Answer)
Gender (Multiple Choice: Male / Female / Other)
Occupation (Short Answer)
Marital Status (Multiple Choice: Single / Married / Divorced / Widowed)
Contact Number (Short Answer)
Email ID (Short Answer)
Address (Paragraph)
—
SECTION 2: Present Complaints
Chief Complaint (Paragraph)
(Duration, onset, location, sensation, modalities, associated symptoms)
Causation (If known): (Short Answer)
Aggravation (What makes it worse?): (Short Answer)
Amelioration (What makes it better?): (Short Answer)
—
SECTION 3: General Symptoms
Tongue Appearance (Short Answer)
Thirst (Amount & Preference): (Short Answer)
Sweat (Location, Time, Odor): (Short Answer)
Urine (Frequency, Color, Burning): (Short Answer)
Stool (Consistency, Frequency, Any Trouble): (Short Answer)
Sleep (Quality, Position, Disturbance): (Short Answer)
Dreams (Type/Frequency): (Short Answer)
Sensation of Burning (If any): (Short Answer)
—
SECTION 4: Food & General Desires/Dislikes
Food Cravings: (Short Answer)
Food Aversions: (Short Answer)
Desire for Cold/Hot Drinks: (Short Answer)
Any food that aggravates symptoms: (Short Answer)
—
SECTION 5: Mental & Emotional State
Temperament (Irritable, Sad, Calm, Reserved): (Short Answer)
Can be consoled easily? (Multiple Choice: Yes / No / Sometimes)
Social behavior (Introvert/Extrovert): (Short Answer)
Fears (Snakes, Ghosts, Darkness, Loneliness, etc): (Short Answer)
Any anxiety, depression, suicidal thoughts: (Short Answer)
—
SECTION 6: Past & Family History
Past Illnesses (e.g., Jaundice, Typhoid, Skin diseases): (Short Answer)
Surgical History (If any): (Short Answer)
Family History (Diabetes, Tuberculosis, Cancer, etc.): (Short Answer)
—
SECTION 7: Thermal Reaction & Physical Constitution
Sensitivity to Cold/Heat: (Multiple Choice: Cold / Heat / Both / Neither)
Build (Thin / Fat / Muscular / Normal): (Short Answer)
Tendency to Catch Cold: (Yes / No)
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SECTION 8: Miasmatic Background
Which miasm seems most dominant based on this case?
(Multiple Choice)
Psora
Sycosis
Syphilis
Tubercular
Mixed (Psora + Sycosis + Syphilis)
—
SECTION 9: Remedy Selection Reasoning
(To be filled by the homeopath after analysis)
Reasons for selecting this remedy: (Paragraph)
1.
2.
3.
4.
5.
6.
—
SECTION 10: Prescription Plan
Suggested Remedy: (Short Answer)
Potency: (Short Answer)
Dosage & Frequency: (Short Answer)
Mode of Administration: (Short Answer)
Next Follow-up Date: (Date)
# রোগীর নামঃ
# বয়সঃ
# পেশাঃ
# লিঙ্গঃ
# বৈবাহিক অবস্থাঃ
**১. বর্তমান সমস্যাঃ**
(কী সমস্যা, কতদিন ধরে, কখন বাড়ে/কমে)
**২. কজেশনঃ**
(সমস্যার কারণ কী মনে হয়?)
**৩. Modalities:**
– বৃদ্ধি (Aggravation):
– হ্রাস (Amelioration):
**৪. জিহবাঃ**
(রঙ, আবরণ, শুকনো/আর্দ্র)
**৫. পিপাসাঃ**
(তৃষ্ণা আছে? কী ধরণের পানি?)
**৬. ঘামঃ**
(কোথায়, কখন, গন্ধ আছে কি?)
**৭. পছন্দঃ**
(পছন্দের খাবার বা অভ্যাস)
**৮. অপছন্দঃ**
(অপছন্দের খাবার বা অভ্যাস)
**৯. প্রস্রাবঃ**
(স্বাভাবিক/কষ্টকর/বারবার)
**১০. মলঃ**
(নিয়মিত/কষ্ট/শুকনা/ঢিলা)
**১১. ঘুমঃ**
(ভালো/ভাঙ্গে/ঘুম আসে দেরি করে?)
**১২. স্বপ্নঃ**
(প্রকৃতি – ভয়ানক/সাধারণ/বারবার)
**১৩. জ্বালাভাবঃ**
(কোথায় হয়, কেমন সময় হয়)
**১৪. ঠান্ডা লাগার প্রবণতা:**
(সহজে ঠান্ডা লাগে কি?)
**১৫. পূর্বের বড় রোগ/ইতিহাসঃ**
(যেমনঃ জন্ডিস, টাইফয়েড, স্কিন সমস্যা)
**১৬. ফ্যামিলি হিস্টরি:**
(ডায়াবেটিস, টিবি, ক্যান্সার ইত্যাদি)
**১৭. ভয়:**
(সাপ, ভূত, অন্ধকার, একা থাকা)
**১৮. মানসিক লক্ষণ (Mind):**
– মন সহজে ভেঙ্গে যায়?
– সহজে কনসোল হয়?
– সবার সাথে মেশে কি না?
– রাগ/দুঃখ/হতাশা কেমন?
**১৯. ধাতুগত অবস্থাঃ**
(চিকন/মোটা/হাইপার/স্লো/খুব খায় কি?)
**২০. মায়াজমেটিক বিশ্লেষণ (Miasm):**
✅ সোরা
✅ সাইকো
✅ সিফিলিস
✅ টিউবারকুলার
✅ মিশ্র (যদি থাকে)
**২১. ঔষধ নির্বাচন করলাম কারণঃ**
১)
২)
৩)
৪)
৫)
৬)
**২২. প্রস্তাবিত ঔষধঃ**
– নামঃ
– শক্তিঃ
– মাত্রাঃ
– প্রয়োগঃ
– ফলোআপঃ
Patient Details
Patient Name:
Age:
Occupation:
Gender:
Marital Status:
—
1. Present Complaints:
(What is the complaint? Duration, when it increases/decreases)
—
2. Causation:
(What do you think caused this problem?)
—
3. Modalities:
Aggravation (What makes it worse?):
Amelioration (What makes it better?):
—
4. Tongue:
(Color, coating, dry or moist)
—
5. Thirst:
(How much water is consumed? Type – cold/warm, frequent or rare?)
—
6. Sweat:
(Location, time, any odor?)
—
7. Cravings (Likes):
(Food or habits the patient likes)
—
8. Aversions (Dislikes):
(Food or habits the patient dislikes)
—
9. Urination:
(Normal / Painful / Frequent / Any issues)
—
10. Stool:
(Regular / Constipated / Dry / Loose)
—
11. Sleep:
(Quality – good/broken / delayed onset, etc.)
—
12. Dreams:
(Nature – scary, normal, repetitive)
—
13. Burning Sensation:
(Where does it occur and at what time?)
—
14. Tendency to Catch Cold:
(Does the patient easily catch cold?)
—
15. Past Medical History:
(e.g., Jaundice, Typhoid, Skin conditions)
—
16. Family History:
(e.g., Diabetes, Tuberculosis, Cancer, etc.)
—
17. Fears:
(e.g., Snakes, Ghosts, Darkness, Being alone)
—
18. Mental Symptoms (Mind):
Is the patient emotionally sensitive?
Can be consoled easily?
Social behavior – mixes with people or reserved?
Nature of anger/sorrow/depression, etc.
—
19. Physical Constitution:
(Slim / Obese / Hyperactive / Slow / Appetite level, etc.)
—
20. Miasmatic Analysis:
✅ Psora
✅ Sycosis
✅ Syphilis
✅ Tubercular
✅ Mixed (Psora + Sycosis + Syphilis)
—
21. Reasons for Remedy Selection:
1.
2.
3.
4.
5.
6.
—
22. Final Prescription:
Remedy Name:
Potency:
Dosage:
Mode of Administration:
Follow-up Date: