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Consult Online
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Name
*
First
Last
Phone
*
Email
Address
*
Chief Complaint
*
Duration, History of chief complaints. (viz. How the complaint had started? How it developed? What are the events during the course? and any other relevant data)
Sex
*
Male
Female
Transgender
Marital Status
Yes
No
Age
*
Height
*
Weight
*
Bad Habits if any
Smoke
Drink
Drugs
Nutritional Status
Best
Good
Poor
Worst
Appearance
Well Built
Athletic
Under Weight
Over Weight
Obese
Hair
Normal
Baldness
Local Baldness
Diffuses
Hair Falling
Skin
Normal
Dry
Oily
Nail
Normal
Thick Nails
Ingrowing Nails
Discolouration
Appetite
Normal
Good
Poor
Worst
Thirst
Normal
Thirsty
Thirstless
Sleep
Normal
Sound
Disturbed
Unrefreshing
Dream
Normal
Often
Rare
Repetitive in theme
Craving
None
Food
Sweet
Bitter
Meat
Egg
Fish
Salt
Pungent
Aversion
None
Milk
Egg
Sweets
Bowel
Normal
Regular
Hard
Constipated
Urine
Normal
Frequently
Pain Before
Pain During
Pain After
Sweat
Normal
Second Offensive
Third Choice
Decreased
Sweat general
Whole Body
Local Head
Axilla
Face
Any other body part
Sexual Function
Normal
Good
Poor
Worst
Past History
Any illness or similar ailment in the past, Treatment history What all treatments taken for this ailment or any other ailment? And add a list of medicines taking and for what ailment?
Other Symptoms
General Examination
Milestones of Developments
Systemic Examination
Add any symptom from Head to foot or any examination findings.
Head, Scalp, Eye, Ear, Nose, Mouth, Teeth, Face, Tongue, Respiratory, Cardiovascular, Genitourinary, Gastro intestinal tract (from mouth to rectum and anus)
Reaction to Hot Weather
Like
Hate
Just OK
Reaction to Cold Weather
Like
Hate
Just OK
Reaction to Warm food
Like
Hate
Just OK
Reaction to Cold food
Like
Hate
Just OK
Reaction to Warm water
Like
Hate
Just OK
Female Complaints
Before, During and After Menses
Mind
Add a detailed summary of all the emotional mental intellectual subconscious sensations and functions felt by you
Detailed list of Investigation reports
Any other Relevant information
Phone
Submit
0471-2591352
9447051352
0471-2597788
9400332813
santhoshraghav@rediffmail.com
9 am to 9 pm
9 am to 12 noon on Sunday
R V Homoeo Clinic & Research Centre Center Point, Sreekariyam-PO Trivandrum-695017, Kerala, India