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QUESTIONNAIRE
Introduction: (to be put before the questionnaire to explain the purpose of case taking) Please fill in this questionnaire in detail. Some things may not be medically relevant but for a homoeopath it may be important for curing your ailments. Of particular importance are the changes you have noticed in your behavior, temperament, and attitude. Physically, in your appetite, desires and aversions for particular foods, bowel habits, sleep patterns and dreams. So, please fill in the questionnaire in detail. IDBI_Bank_Logo
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Consultation Form
Patient's Name : 
   
Date of Birth  : 
   
Occupation : 
   
Address : 
   
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Contact No : 
   
Email Id : 
   
   
Your constitution: Are you lean, thin, obese, pot – belied? Do you feel tired or energetic at most times of the day? Chief Complaints:
Please write in detail about the onset, exact location of the Complaints, Sensation, Modalities (better by or worse by - as regards time, position, relation to heat and cold, season) your mental state regarding family, work, environment, fears, just before the onset of disease and few years prior to it.
 

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