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NCH - Questionnaire for Homeopathic Patient

NCH - Questionnaire
--------------------------
http://www.nch.ipbfree.com
A homoeopath needs to know some more information besides knowing your name of disease, like location of illness, organ affected, type of sensation, modalities, mental & physical disorders, causations, concomitants strange or rare or peculiar symptoms, personal history of illness, family history with serious or chronic sickness.

This information will help the homeopath to select a proper medicine for you. If you are not sure about the answer of some the questions mentioned below, please leave them blank but do not fill with wrong entries. Underlined entries are most important to answer. You may get help from your Medical Nursing Staff before submitting this proforma. (Homeopath)
-------------------------------------------------------------------------------
Personal Information:
-------------------------
Full Name:
(You can use your alias if you want to be anonymous)
Sex:
Age:
Weight:
Height:
Temperature:
Blood Pressure:
Color of Tongue:
Occupation:
Optional Information:
-------------------------
City:
Country:
Phone:
(With city and country codes)
Email Address:
-------------------------------------------------------------------------------
Detail Patient History
-----------------
Name of Disease:-
(Diagnosed by Your Medical Doctor
Or if you know the name of your disease)

Patient Description:-
(Important: Write your major complaints
& symptoms briefly in your own words priority wise.)

Cause of your disease / Problem:
(If you don’t know leave it blank)

Period of Disease / Complaints:
(Day, Month or Year when it was started)

Results of major Laboratory Tests:
(Investigations / Pathology Reports)
a.
b.
c.

Comfortable Position:-
(Which activity / position / work
make you better and provide relieve
in your disease or problem?)
Worse state of disease:-
(Which activity / position or work
when perform make you discomfort
and creates uneasiness or pain?)

Change of Weather:-
(Does change in hot and cold
season have any impact on your
disease or symptom?)
Hot & Cold Application:-
(How do you feel in hot or cold
application or when you take bath
or live in warm or cold room)

Good Time:
(At what time you feel trouble-free
or comfortable or painless?
Morning / forenoon / evening / night etc?)
Worse Time:
(At what time you feel uneasiness or discomfort?
Morning / forenoon / evening / night etc?)

Thirst:-
(How is your thirst?)
Appetite:-
(How is your appetite?)

List of medicines used so for:
(Homeopathic and allopathic or Herbal, if any etc)
a.
b.
c.

Habits:
(Explain in detail where necessary)
Are you addict of alcohol?
Are you a smoker?
Are you fond of drinking tea?
Do you like salty/spicy items or sweet stuff?
Are you vegetarian or carnivore?
How is your bowel movement?
(Loose motion or constipation etc)
Are you slim smart or obese etc?
Do you have craving for any food / drink etc?
Do you have any wart or mole on your body?
(First check your body with care)

List of your major past illnesses / diseases:-
(examples: Mumps, chicken pox, whooping
cough, pneumonia, malaria, typhoid etc)
a.
b.
c.


List of major closed family persons diseases:-
(Examples: Asthma, Cancer, Diabetes
High Blood Pressure, Rheumatism or T.B)
a.
b.
c.
Detail of your past Vaccination Chart:-
(If you remember)
a.
b.
Further Explanation:-
(If not covered above)

Prepared By:
http://www.nch.ipbfree.com & http://www.nchpakistan.com
 
  ABC Hompath on 2005-11-18
This is just a forum. Assume posts are not from medical professionals.
This I found a simple but comprehensive questionnaire for filing case at www.abchomeopathy.com forum.

Those patients who are interested for classical homeopathic prescription are directed to fillout this proforma and submit your case where ever you are interested to post.

This questionnaire is also helpful in chronic and acute cases.

Homeopath
 
ABC Hompath last decade
Color Edition is available at this site:

http://www.communitypk.com/homeopath/nch.htm

Enjoy reading and filling the post.
 
ABC Hompath last decade
I appreciate the input of this user. Good work

http://www.5wwwww5.com/forum/index.php?mforum=nch

The NCH forum is moved at another place for the time being. As quoted through email and as intimated at various forums.

Regular members can join it again.
 
Dr SS last decade
This seems to me a comprehensive web page have all the relevent basic questions to ask to patient.
 
Pakistani last decade
Bringing this up.
 
Cordial last decade
To Mr Joe,
Thanks for quick response. I am sending the required information as desired by you.

1. Name: shasif
2. Sex male
3. Age 65
4. Weight 130 lbs
5. Height 5 ft 5 in
6. Temp normal (96.5 F)
7. BP: ranges between 110/70 to 140/80 with medication Diaovan 160mg
8. Color of tongue: white appears somewhat coated at this time.
9. Occupation: Retired from senior position in government.
10. City: Islamabad
11. Pakistan
12. E-mail:
13. Name of diseases:
Coronary heart. received two stents in 2004, which are working satisfactorily. Last engio was done on 12 Feb 2009.
14. Prostritis. Enlarged prostrate since 1998. First took sabal serruluta Q but casually. Started with cardura in 2004 but soon shifted by Urologist to flowmax and proscar in 2005. Size rduced from from 65 to about 37 gm and when I stopped proscar it again increased to 68 gms and then Urologist started avodart with flowmax and last ultra sound was done in July 2009 and size reduced to 38gms and post void was negligible. Avodart was stopped in july a2009 and flowmax on 15 feb 2010. Now I am mainly on R25. In addition, I do take of and on Conium 200, canthris 200, or thuja depending on symptoms.
15. Borderline diabetes since 2005. I take Amarly 1mg. In addition started Syzegium Q 1X about 1 week ago. I also take cinnamon 1/2 tsp
16. Glaucoma. Since 2006. Eye Pressure under control (10/10). Taking Naphthaline 200 and eye drops Trusopt. With left eye I see objects small and blurred and lines are wavey. In right eye I have floaters and flashes in right corner. Seeing with both eyes I have no problem.
17. I have knots on right hand palm which are better after I took medicine from homeopath. I had a lump in right leg which got dissolved by taking lot of Augmentin and Calc flour. I still feel dull pain in the same area but apparently no lump.
18. I have a small 3/4 inch almost square spot on left cheek for the last 10 years. Biopsy was done and diagnosis is 'sub acute eczema' I am under treatment of skin spslt whose has given me Teczam and Advantan creams for local application. Recovery is slow/uncertain.
19. patients description. I need to go to wash room more frequently. During day time I need to go every 1 to 2 hours. At night I some time get up once. Before starting R-25 I used to go at least twice. I get a feeling that few drops are struck in the urinary tract. When going out I must visit 2 or 3 time to push out last drops and then I stay comfortable for 2 or may be 3 hours. Stream is weak. Sometimes stream is forked and rarely like a shower.
20. About 2 month back I felt that I was staggering or going right or left instead going straight. My Homeopath gave me conium, I think, and it improved. Some time I feel light headed and within few seconds it becomes alright.
21. Once in a while I get pain on the right or left pelvic area near rectum. Homeopath said it was problem of nerves and gave some medicine and it improved. Recently I had couple of episodes gain.
22. Impending hernia right side since 2004. I take Lycopodium 1M as needed. Some time slight pain is also felt in testicles.
23. Lab reports: BS (Fasting ) 109 and HbA1c- 6.0
Cholestrol- 165
Triglycerides- 134
HDL- 47
LDL- 94
ESR- 10
Uric acid- 3.4
serum creatinine: 1.2
serum bilirubin- 1.0
ALT/SGPT- 22
Alkaline Phosphate- 106
CRCP:
 
shasif 9 years ago
To Joe,
Sorry I missed one thing. I also have acidity problem. I took a number of homeopathic remedies in the past but it did not help. Presently I, am taking Nexum 20mg one capsule a day and it helps. Recently went through endoscopy and it was clear. Thank God no ulcer. So Dr gave me Nexum.

In early 70s, I had kidney pain and had a stone Calcium oxalate. Thanks to homeopathic medicine, the stone cleared one day in 1983.
Thanks. I think I have given you lot on information and my medical history.
Advice please.
 
shasif 9 years ago
Hi Joe
here is my questionnaire.
Full Name: Bol
(You can use your alias if you want to be anonymous)
Sex: Male
Age: 36
Weight: 101kg
Height: 186cm
Temperature: Normal
Blood Pressure: Normal
Color of Tongue: Normal (Pink)
Occupation: Tree Lopper
Optional Information:
-------------------------
City:
Country: Australia
Phone:
(With city and country codes)
Email Address:
-------------------------------------------------------------------------------
Detail Patient History
-----------------
Name of Disease:-
Obstructed Bladder Neck

Patient Description:-
Frequency and Urgency of Urination, soemtime the feeling of not completly emptying of bladder. No pain.

Cause of your disease / Problem:
(If you don’t know leave it blank)

Period of Disease / Complaints:
(3 years, March 2007

Results of major Laboratory Tests: Normal
(Investigations / Pathology Reports) Normal
a.Normal
b.Normal
c.

Comfortable Position:-
Makes no difference.

Change of Weather:-
Makes no difference

Good Time:

(At what time you feel uneasiness or discomfort?
Morning / forenoon / evening / night etc?) It doesn't change with time of day.

Thirst:-
(How is your thirst?) Normal
Appetite:-
(How is your appetite?) Normal

List of medicines used so for:
(Homeopathic and allopathic or Herbal, if any etc)

a. Ventolin for Asthma
b.
c.

Habits:
(Explain in detail where necessary)
Are you addict of alcohol? I drink 3-4 beers most days but not every day
Are you a smoker? ex smoker
Are you fond of drinking tea? sometimes but not coffee

Do you like salty/spicy items or sweet stuff? Salty and spicy.

Are you vegetarian or carnivore? Carnivore

How is your bowel movement?
(Loose motion or constipation etc) sometimes normal sometimes loser. I have a bit of bowl trouble from time to time. It feels like Irritable Bowel Syndrome.

Are you slim smart or obese etc? slightly over weight.

Do you have craving for any food / drink etc?
Depends on mood

Do you have any wart or mole on your body? very small wart on hand and on face, and I just had a mole removed from my leg a few weeks ago

(First check your body with care)

List of your major past illnesses / diseases:-
(examples: Mumps, chicken pox, whooping
cough, pneumonia, malaria, typhoid etc)
a.Asthma
b.Chicken Pox in 2000
c.


List of major closed family persons diseases:-
(Examples: Asthma, Cancer, Diabetes
High Blood Pressure, Rheumatism or T.B)
a.Asthma
b.Diabetes
c.

Detail of your past Vaccination Chart:-
(If you remember)
a.Hep A and B
b.Typhoid
Further Explanation:-
(If not covered above)
 
easygroove 9 years ago
Does any one know where I can find the color NCH form spoken of here? Both websites are no longer active.

Thanks,

~Jay
 
jaymethunt 9 years ago
Full Name: Jon Bon Jovi
(You can use your alias if you want to be anonymous)
Sex: Male
Age: 32
Weight:105 kg
Height:181 cm 5'11'
Temperature: Normal
Blood Pressure: 130/85
Color of Tongue: Faded and Cracky
Occupation: Unemployed at the moment
Optional Information:
-------------------------
City:Melbourne
Country: Australia
Phone:
(With city and country codes)
-------------------------------------------------------------------------------
Detail Patient History
-----------------
Name of Disease:- Hypertension, Asthma
Patient Description:-
Stiff Neck Muscles, Asthma, Obesity, Ache in Joints of big Toes of Both Feet, Ache in Point finger and middle finger of right hands, Hypertension, Post Nasal Drops (Thick Mucous), Fatty Liver (Non-Alcoholic), High Cholesterol,


Period of Disease / Complaints:
Asthma 1999
Hypertension 2004

Results of major Laboratory Tests:
(Investigations / Pathology Reports)
a. Low Testosterones
b. High ALT and AST enzymes (Liver Fat)
c. High Cholesterol

Comfortable Position:-
Laying on ground for Stiff Neck
Change of Weather:- Doesn't matter much. Cold weather brings more mucous. Eating hot food make my face sweat. Purging brings perspiration around anus

disease or symptom?)
Hot & Cold Application:-
Take hot shower all year round and go to swimming pool for aqua exercises.
Good Time:
night, just about to go to bed
Worse Time:
when I am thinking of past episodes

Thirst:-
feel thirstier:- Yes but not much
Appetite:-
OK

List of medicines used so for:

a. Atacand, Olmecip, Presolar, Amlodipine (High Blood Pressure)
b.Flixotide, Ventolin (Asthma)
c.Various Ayurvedic medicines to lower blood pressure and cholesterol
d. Prednisolone for Nasal Polyps

Habits:
Going for long walk, Aqua exercises, sitting or lying in front of computer for a long time
Are you addict of alcohol?NO
Are you a smoker? NO
Are you fond of drinking tea?
Yes
Do you like salty/spicy items or sweet stuff?
No
Are you vegetarian or carnivore?
Carnivore
How is your bowel movement?
(Loose motion or constipation etc)
OK, bad after very heacy food.
Are you slim smart or obese etc?
Overweight
Do you have craving for any food / drink etc?
craving for good healthy food
Do you have any wart or mole on your body?
A lump just near the right shoulder blade on the back.

List of your major past illnesses / diseases:-
None except Tonsillectomy and Polypectomy Operations
List of major closed family persons diseases:-

a.Fatty Liver
b.High Blood Pressure
c.Rheumatism
d.T.B
Detail of your past Vaccination Chart:-
Swine Flu Vaccine (Had a very bad reaction, nearly got killed)
a.
b.
Further Explanation:-
(If not covered above)
 
bonjovi 9 years ago
Full Name:
(You can use your alias if you want to be anonymous)
Sex: male
Age:33
Weight:5.10
Height:165 pounds
Temperature:normal
Blood Pressure:normal
Color of Tongue:pinky
Occupation:
Optional Information:
-------------------------
City:montreal
Country:canada
Phone:
(With city and country codes)
Email Address:
-------------------------------------------------------------------------------
Detail Patient History
-----------------
Name of Disease:-dont know
(Diagnosed by Your Medical Doctor
Or if you know the name of your disease)

Patient Description:-7 months with a very bad chronic throat burning,heartburns
(Important: Write your major complaints
& symptoms briefly in your own words priority wise.)

Cause of your disease / have Problem:
(If you don’t know leave it blank)

Period of Disease / Complaints:Dec 09
(Day, Month or Year when it was started)

Results of major Laboratory Tests: HIV/Throat cancer
(Investigations / Pathology Reports)
a.negative
b.negative
c.

Comfortable Position:-
(Which activity / position / work
make you better and provide relieve
in your disease or problem?)walking outside
Worse state of disease:-
(Which activity / position or work
when perform make you discomfort
and creates uneasiness or pain?)after lunch throat is killing me for the rest of the day

Change of Weather:-
(Does change in hot and cold
season have any impact on your
disease or symptom?)
Hot & Cold Application:-
(How do you feel in hot or cold
application or when you take bath
or live in warm or cold room)

Good Time:
(At what time you feel trouble-free
or comfortable or painless?
Morning / forenoon / evening / night etc?)
Worse Time:evening
(At what time you feel uneasiness or discomfort?
Morning / forenoon / evening / night etc?)

Thirst:-good
(How is your thirst?)
Appetite:-good
(How is your appetite?)

List of medicines used so for:
(Homeopathic and allopathic or Herbal, if any etc)
a.
b.
c.

Habits:
(Explain in detail where necessary)
Are you addict of alcohol?no
Are you a smoker? use to i quit in dec 09 because my throat was hurting
Are you fond of drinking tea? started 1 week ago, fruit base
Do you like salty/spicy items or sweet stuff? i quit the spicy but still use salt
Are you vegetarian or carnivore?carnivore
How is your bowel movement?
(Loose motion or constipation etc)loose
Are you slim smart or obese etc?slim smart
Do you have craving for any food / drink etc? no
Do you have any wart or mole on your body? none
(First check your body with care)

List of your major past illnesses / diseases:-
(examples: Mumps, chicken pox, whooping
cough, pneumonia, malaria, typhoid etc)
a.
b.
c.


List of major closed family persons diseases:-
(Examples: Asthma, Cancer, Diabetes
High Blood Pressure, Rheumatism or T.B)
a.
b.
c.
Detail of your past Vaccination Chart:-
(If you remember)
a.
b.
Further Explanation:-
(If not covered above)
 
patmatrix 9 years ago
Personal Information:
-------------------------
Full Name: s.sethi
(You can use your alias if you want to be anonymous)
Sex:Female
Age: 27yrs
Weight:84Kgs
Height:5'1
Temperature:37
Blood Pressure:
Color of Tongue:Red / Pink
Occupation:WebDesiger
Optional Information:
-------------------------
City:
Country:
Phone:
(With city and country codes)
Email Address:
-------------------------------------------------------------------------------
Detail Patient History
-----------------
Name of Disease:-
(Diagnosed by Your Medical Doctor
Or if you know the name of your disease)
Servical spondilytus, headaches, obesity

Patient Description:-
(Important: Write your major complaints
& symptoms briefly in your own words priority wise.)

had a bone missing in my ankel - left foot from birth coz of which have been operated thrice , medicines had stioroids used had affted me with overweight and blood pressure which shoots sometimes, i dont have medicines now for my foot

Servical spondilytus - pain in shoulders, neck followed by headache

Cause of your disease / Problem: feeding baby - wrong posture while sitting and sleeping
(If you don’t know leave it blank)

Period of Disease / Complaints: few months
(Day, Month or Year when it was started)

Results of major Laboratory Tests:
(Investigations / Pathology Reports)
a.
b.
c.

Comfortable Position:- sitting with a bcak rest
(Which activity / position / work
make you better and provide relieve
in your disease or problem?)
Worse state of disease:-working , bending neck sometimes
(Which activity / position or work
when perform make you discomfort
and creates uneasiness or pain?)

Change of Weather:-
(Does change in hot and cold
season have any impact on your
disease or symptom?)
Hot & Cold Application:-
(How do you feel in hot or cold
application or when you take bath
or live in warm or cold room)

Good Time:
(At what time you feel trouble-free
or comfortable or painless?
Morning / forenoon / evening / night etc?)
Worse Time: morning and night
(At what time you feel uneasiness or discomfort?
Morning / forenoon / evening / night etc?)

Thirst:- normal
(How is your thirst?)
Appetite:-nbormal
(How is your appetite?)

List of medicines used so for:
(Homeopathic and allopathic or Herbal, if any etc)
a.Baledona 30 (sometimes - as i see no effect for headaches)

b. NAt Phos 6x for overweight - as suggested by Doc Joe

c.Dashmularishtha and Ashokarishtha

Habits:
(Explain in detail where necessary)
Are you addict of alcohol? NO
Are you a smoker?NO
Are you fond of drinking tea? 1-2 cups in a day
Do you like salty/spicy items or sweet stuff? moderate of salty and sweet
Are you vegetarian or carnivore? have non - veg sometimes
How is your bowel movement? normal
(Loose motion or constipation etc)
Are you slim smart or obese etc? -obese
Do you have craving for any food / drink etc? NO
Do you have any wart or mole on your body? mole on my face on my chin
(First check your body with care)

List of your major past illnesses / diseases:-
(examples: Mumps, chicken pox, whooping
cough, pneumonia, malaria, typhoid etc)
a.
b.
c.


List of major closed family persons diseases:-
(Examples: Asthma, Cancer, Diabetes
High Blood Pressure, Rheumatism or T.B)
a.Diabetes
b.
c.
Detail of your past Vaccination Chart:-
(If you remember)
a.
b.
Further Explanation:-
(If not covered above)
 
saisethi 9 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.