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Homoeopathic Questionnaire Template

This is an abbreviated version of Dr. Dinesh Chauhan's questionnaire used in his online clinic. I have seen Dr. Chauhan speak and he is a very experienced and highly learned homoeopath.

HOW TO DESCRIBE YOUR COMPLAINTS

In homoeopathy, prescription is based on precise details of various symptoms from which you suffer. To tell or write to a homoeopathic physician 'I have a headache ', ' an eruption ' or “a cough” would not be enough. If you inform him 'I have headache with sharp shooting pains in the left side of the head and temple, these pains always come on when the slightest cold air strikes the head. I feel better by pressing the head very hard.” Then only you have given all the information required for making a good homoeopathic prescription. The success of the prescription depends; largely on how detailed your description of the symptoms is.
We require the following details about your symptoms.

LOCATION: Please give the exact location of sensation, pain or eruption. Also describe where the pain or sensation spreads.

SENSATION: Express the type of sensation or the pain that you get in your own words however simple or funny it may seem. You may have a sensation that a mouse is crawling or the heart was grasped by an iron hand or you may have a pain that is cutting, burning jerking, pressing. Express the sensation or pain as it feels to you. Try to explain the whole sensation in the exact way it is happening and not just the word. We need to understand the whole process of the sensation as it is happening to you.

WHAT MAKES YOU WORSE OR BETTER: Many factors are likely to influence your complaint. Some factors may intensify it and some factors may relieve the trouble. A detailed list of the factors is given at the end. Please refer it while describing each of your troubles and indicate which factors make the complaint better or worse.

DISCHARGES: You may have a discharge from nose, ears, mouth, eyes, ulcers, fistula, eruptions on skin, private parts, etc. Please describe your discharge under the following aspects.

• The quantity and the time or condition under which the quantity varies i.e. when is it better or worse, when does it increase or decrease?
• The consistency: Is it thin or thick, stringy or clotted?
• Is it like jelly, white of an egg, like water, sticky forming a scab etc.?
• The odour, what does it remind you of?
• Does it make the parts sore, and in what way?

1] Your Complaint:
(Use your own words as far as possible, but if you have recognized or diagnosed the condition, give this information also.) By answering as many of these questions as fully as possible, you are helping me to understand what your body and unconscious mind is conveying. This can help me find a remedy for you.)

• What is your complaint?
• When did the complaint begin?
• Where is it located?
• What sort of sensations (and emotions) do you associate with it?

The following are examples of what you may experience:

o Pain (if so what sort of pain, e.g. burning, stabbing)
o Heat or cold
o Trembling
o Pins and needles
o Numbness
o Fear or anger
• Does anything make it better or worse?
• How does it bother you? How is it coming in way of your day-to-day life?
• How does it feel like to have this/these problem/s?
• What is the effect of this/these problem/s on you?
• Did any event happen which caused the complaint? Describe the emotion associated with it.
• What are the other symptoms started with it, esp. mental and physical symptoms, which are not directly related to the main complaint.
What are your reactions with it?


MIND
________________________________________
1] What are the issues which are bothering you the most? How does it feel to have these issues? What about these issues bothering you the most and why?
2] What are the emotions that you are going through? What are the factors to which you are sensitive? What about these factors bother you the most? How does it feel to have these factors and how you react during such time?

3] Any incident which had a deep impact on you? Describe in detail. What are the thoughts/feelings/sensations associated with it? At that moment of time what were your feelings/thoughts, sensations and reactions associated with it?
(Note: Incidents might have happened long ago and now it has no impact on you but at that moment of time if it had any impact on you, describe.)
4] What are your anxieties/fears/phobias real or imaginary? Describe them in detail. What about them is bothering you the most? What are the feelings associated with it? What could be the worst form of fear/phobia/anxiety according to you?
5] What are your interests and hobbies? What about it you like the most and why?
6] What are the thoughts which are coming in your mind again and again? What about them bothers you the most?
7] Any unusual sensation/vibration or movements have you experienced? If yes, describe them in detail. Describe the whole process of that sensation without adding or subtracting a word from it.
8] What is/are the bodily sensation/s you experience with all your fears/ feelings and thoughts. Please describe the complete picture of it.
9] Please close your eyes and bring that incident, feelings, fears, thoughts which had/having a deep impact on you/bothering you the most and see what is happening deep within your body right now. If you perceive any bodily sensation, vibration or movements please feel it completely and then right the whole experience as it is without adding or subtracting a word from it.
10] What according to you will be best moment of your life? How does it feel to be in that moment? What will be opposite feeling of this moment or feeling?
11] How do/did you react in situations which have/had a deep impact on you? What is your first reaction when you face your worst fear/situations? Describe your reaction as it is? How do you react when you are faced with stressful situations?
12] What you feel/feel like doing when you are alone and free of all your work?
13] How is your relation with your near and dear ones, at your work place? Anything in the relationship that is bothering you the most? If yes, describe that in detail? How does that feel like? How do you experience that?

14] Describe five negative and positive points in you? Which out of it you would put first and why? How does it feel to have that? ________________________________________

DREAMS
“If we nurture our dreams, they will take root in our souls and bear fruit in our lives”


“USING YOUR DREAMS HOMOEOPATH CAN FIND YOUR TRUE DEEPER SELF”

At the center of most of our dreams, lies the way we feel, think, perceive and sense our problems, our self and the world around us. Our deeper self appear as other characters in dreams, sometimes as people we know, sometimes as strangers, sometimes as animals, forces of nature, sometimes as some symbols, or monsters.

Every object, person, place, and situation in a dream may have many meanings. Each dream can tell us what is happening in the sub-conscious mind. What is important for the homeopath is not only to know the dreams but the thought, feeling, perceptions, and sensations associated with it and also how one reacts and copes-up with it.
Try not to 'interpret' a dream. If you put yourself or others on the spot to 'tell me what it means' then you are taking the wrong attitude toward working with the dream. It's not a game of Jeopardy or a multiple-choice test where there is any right or wrong answer. Tell us the whole dream as it is without adding or subtracting a word from it.

Please answer the following:

1] Tell about the dreams that had a deep impact on you.

2] Tell about the dreams that are repetitive, strange and weird that are not related to you at all.
3] Any dreams from childhood till today that you remember the most?
4] Any dream from childhood till today that had a deep impact on you?
5] Any dreams, just before your problem started?
6] Any particular part of your life where you had some recurrent dreams? If yes, describe in detail.
7] Describe all the dreams you got during the pregnancy?
If you have any dreams from above mentioned category, then describe the whole dream/s without adding or subtracting a word from it. We need to understand the whole dream rather than just part of it.

A] Which part of this/these dream/s is most important according to you? Describe that part in detail?
B] What was your thought/fear/feeling/perception associated with it? Describe it in detail.
C] Did you perceive any movement/vibration/sensation inside your body while seeing or after waking up from the sleep? If yes, then describe it in detail.

(Note: If you don’t remember the whole dream then you can mention the fragment of a dream that you remember? Tell us what was the most important part in that dream.)

CHILDHOOD HISTORY
1] Any incidents from your childhood which had a deep impact on you, which touched you the most. Describe in detail about that incident/s and the feelings/thoughts/perception and sensations associated with it. What was your reaction to these incidents?
2] Describe your fears during childhood in detail.
3] Any imagination/fantasies/imaginary fears which you remember the most?
4] What you wanted to become as a child and why?
5] During acute conditions like fever/diarrhoea/cough/vomiting etc., did you use to have nightmares/dreams during or just before the acute illnesses? If yes, describe them in detail about it. ________________________________________


S L E E P

1] Describe your posture in sleep. (On the back, side, abdomen etc.) Are you able to sleep in any position? In which position you can’t sleep?

2] During sleep do you:
a) Snore?
b) grind teeth?
c) Dribble saliva?
d) Sweat?
e) Keep eyes or mouth open?
f) Walk? Talk?
g) Moan? Weep?
h) Become restless? Wake up with a jerk?

3] Describe if anything else is unusual about your sleep: (sleepy, sleeplessness, etc. if so when?) ________________________________________

APPETITE AND THIRST

1] How is your appetite?
2] When are you hungry?
3] What happens if you have to remain hungry for long?
4] How fast do you eat?
5] How much thirst do you have?
6] Any particular time are you especially thirsty?
7] Do you feel any change in your taste and feeling in your mouth?________________________________________

Food/Drink likes and dislikes, and how strongly

STOOL
1] Do you have any problem regarding your stools?
2] When and how many times a day do you pass stools?
3] When is it urgent?
4] Do you have any problem about bowel movements?
5] Do you have to strain for stool? Even if soft?
6] Do you have belching or passing gas? Describe its character.
7] How do you feel after passing gas up or down? ________________________________________



URINATION & URINE
1] Any problem about urine?
2] Any strong smell? Like what?
3] Do you have any trouble before, during and after passing urine?
4] Any difficulty about the flow? Slow to start, interrupted, feeble dribbling etc.?
5] Any involuntary urination? When?



SWEAT/PERSPIRATION-FEVER-CHILL
1] How much do you sweat?
2] Where and on what part do you sweat the most?
3] Do you perspire on the palms or soles?
4] Is the sweat warm, cold, clammy, sticky, musty, greasy, stiffens the linen etc.?
5] What is the smell like? E.g. foul, pungent, sour, and urinous.
6] What color does it stain the clothing?
7] Is the stain easy to wash off or difficult?
8] Any symptoms after sweating?
9] When do you get fever or chill?
10] What brings it on?
11] Do you experience any sense of heat or cold in any part of your body at any particular time? ________________________________________

CHEST-HEART – COLD – COUGH
1] Do you catch cold often? If so, how often?
2] Describe the symptoms, nature of discharge etc.
3] Is there any trouble with your CHEST or HEART?
4] Is there any trouble with your voice or speech?
5] Is there any difficulty in breathing?
6] Do you have cough?
7] Is it more at any particular time? ________________________________________


SEXUAL SPHERE (GENERAL)
1] Any excessive indulgence in sex in past and present ? Any effect on your health?
2] How do you feel after sexual intercourse?
3] Any particular feeling or symptoms appear before, during and after sexual intercourse?
4] Do you suffer from any sexual disturbance?
(Homosexual inclination etc.?)
5] Any habit like (masturbation etc.) in past as well as present? How often?
6] Did you suffer from any venereal disease?
Syphilis? Gonorrhoea?
7] Do you have increased desire or decreased desire for sex?
8] What is the method you use for family planning?________________________________________


FOR MEN
1] Any difficulty in erection?
2] Wanted erection? Unwanted erection?
3] Weak erection? Failing erection? Describe.
4] Any other trouble in sex? Describe in detail.
________________________________________

FOR WOMEN
1] Menses: How are the periods; regular or irregular?
2] At what age did it start?
3] Was there any trouble then?
4] Mention number of days of flow.
5] Menstrual flow: Is there any change in quantity, color, smell or consistency?
6] Are the stains difficult to wash?
7] Have you noticed any variation in quality and quantity of flow during menses?
8] How and when?
9] Do you suffer in any way before, during or after menses? If so, describe.
10] What symptoms did you suffer during menopause?
11] Do you feel the internal parts coming down?
12] Is there any white discharge?
13] If so, mention the nature, color, consistency and smell of discharge.
14] When and under what circumstances is it more or less?
15] Has the discharge any relation to menses?
16] What is the effect of this discharge on your general feeling? Or any of your symptoms?
17] Any itching, excoriation etc. due to discharge?
18] Do you pass any gas from vagina?
19] Any trouble with breasts?


Aggravated or Ameliorated by various Factors


Affected by the Environment in any way, and how does it affect you?

Affected by position in any way?

Affected by some physical activity?

Affected by some mental activity?

Anything else you are sensitive to?
 
  Evocationer on 2014-02-26
This is just a forum. Assume posts are not from medical professionals.
Bumping to keep this where people can see.
 
Evocationer 6 years ago
Nice questionnaire, thanks for sharing.

I wish you see the replies of some of the posters, they only contain Yes/No/Normal as the answer:) Go figure the remedy!
 
fitness 6 years ago
I know it is frustrating. You would think if people are going to seek help from a homoeopath, they would do a little research so that they can offer as much aid to the homoeopath as possible.

People are used to orthodox medical practitioners though, who have no use for details. First part of our job is often to educate them.
 
Evocationer 6 years ago
There is a case which has me stumped, if you can offer some insight that would be great:

http://www.abchomeopathy.com/forum2.php/407004/3

Eversince posting it, I have exchanged several emails with the patient and I believe I know the case very well, still its not budging.
 
fitness 6 years ago
Hi Fitness,

I will have a look over the case today. I have clients throughout the day so it might take me a few hours.

Looks like a complex case though.
 
Evocationer 6 years ago
Thanks, its indeed a complex one. Take your time, neither me nor the patient is in a hurry as he has lost hope.

There have been a few updates that I will start posting once you get the time.

I'd like to have a fruitful discussion on this to clarify my thoughts too.
 
fitness 6 years ago
I should probably tell you what happens when i think about my childhood. I start to break off and I tell myself I have my grandma talking to me to help me see things I wont feel. I did this as a child also but I dont remeber it clearly. My mom told me about it and I remember having her as an imaginary friend. But when I started paychosis thats onw of the big signs. I was in a la la lan with my grabdmother living a spiritual calling. Its funny to think about now but I still catch myself doing it. Im doing it right now. K thought that would be important.
 
Rmaier 6 years ago
Bumping to keep close to top.
 
Evocationer 6 years ago
Bumping again.
 
Evocationer 6 years ago

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Important
Information given in this forum is given by way of exchange of views only, and those views are not necessarily those of ABC Homeopathy. It is not to be treated as a medical diagnosis or prescription, and should not be used as a substitute for a consultation with a qualified homeopath or physician. It is possible that advice given here may be dangerous, and you should make your own checks that it is safe. If symptoms persist, seek professional medical attention. Bear in mind that even minor symptoms can be a sign of a more serious underlying condition, and a timely diagnosis by your doctor could save your life.