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Indoor Case Record Form (Long Case)
OPD Case Record Form (Short Case)
Patient Id no: *Mandatory field
1. Patient Profile*
Name: Age: Sex: Weight: Height: Address: Date:
2. C/C (Chief Complain):
3.Present
Complain: *
Take patient Subjective & Objective symptoms from Head to feet. Complete each symptom with Causation, Location, Sensation, Duration, Modalities, Concomitants, Extension.
4. Past
History: *
Any Disease which suffering yet, Drugs taken, Developmental
defects, Vaccination, Operation, Injury.
5. Personal History:
Habit, Habitat, Sexual history, Relationship with others.
6. Family
History: *
Maternal Disease:
Paternal Disease:
7. Generalities: *
A. Mental General: Willing, Feeling, Emotion, Fear, Depression. Temperament, Memory Power, Shocks. Suspiciousness, Affectionate, Thinking.
B. Physical General:
· Constitution.
· Appetite.
· Digestion.
· Thirst.
· Thermal reaction.
· Elimination (Stool, Urine, Salivation, Perspiration)
· Disease Modalities.
· Bathing.
· Foods Desire & Aversion.
· Sleep & Dream.
C.
Gynecology & Obstetrics Particular Complain:
ü Age of menarche.
ü Menstruation: Regular / Irregular, Volume, Duration, Odour, Colour,
Clotted, Painful or not (Dysmenorrhoea )
ü Leucorrhoea: Itching, Odour , Volume , Stain in cloth , Any
Discomfort.
ü Pregnancy Related complain (Normal / Caesarean Section Delivery)
ü Lochia / Postpartum Haemorrrhage History.
ü Miscarriage History .
ü Gravida / Para.
ü Age of Menopause.
8. General Examination:
Appearance, Co-operation, Decubitus, Clubbing, Cyanosis, Koilonychia, Leukonychia, Lymph node ,Thyroid gland, Breast, Neck Vein ,Build and hair distribution, Nutrition, Anaemia, Jaundice, Dehydration, Oedema, Pulse ,BP , temperature .
9. Systemic Examination: By
Inspection, Palpation, Percussion, Auscultation
10.Provisional Diagnosis:
ü
Lab. Investigation Report:
ü
Confirm Diagnosis:
11. Miasmatic Diagnosis: Psoric /Sycotic / Syphilitic / Tubercular Patient.
Finally
Analysis & Evaluation
of Symptoms. That means which Symptoms you give priority most.
keynotes (which should encompass Peculiar, Queer, Rare,
Strange Symptoms (§153 and §209 of Hahnemann’s Organon)
Repertorization: Use
Synthesis / Kent / Murphy / Complete Repertory Book or Radar / Radar opus /
Zomeo software / Vithoulkas compass.
Medicine
& Potency selection with Dose: .......
Dietary
advice if necessary.
Follow Up
No: ……… Patient Feedback: ………
Second
Prescription Medicine & Dose: ………