PLEASE READ THIS FIRST BEFORE FILLING THIS FORM
• In order to select the right medicine for you , we depend upon your co-operation.
• HOMOEOPATHIC MEDICINE IS MAINLY SELECTED ON THE UNFABRICATED ANDHONEST INFORMATION YOU GIVE TO US.
• To make a successful prescription, you have to give all the INS AND OUTS of your sickness.
• Individually everyone is different with respect to their physical , emotional and mental make up . This includes your reactions to various life situations and the sufferings/ joy you experienced in your life till date , including your feelings/ impressions related to your childhood , here it is also very important to provide detailed information about the sickness / diseases in your family { paternal as well as maternal } .
• In order to find all about you, we shall be asking you many questions. Each one of these questions has a definite meaning and significance for us. There is not a single question useless. Even something that you may think is not connected with your trouble, might be the most important factor in deciding the correct medicine for your sickness .
• That is why you must be free and frank in giving us the complete possible information on each point.
• Please read each question carefully, think, and if necessary, reach out to us through mails , watsapp , instagram @the_passionate_project and then answer completely.
• Do not keep anything hidden.
• Remember, whatever you tell us will remain absolutely confidential.
GENETIC COUNCELLING
In homoeopathy , we treat not only the sick but we can find solutions to many genetic errors and abnormalities which are usually transferred to the next generation by inheritance ex: DEPRESSION , CANCER , DIABETES , HYPERTENSION , HEART DISEASES , ASTHMA , ARTHRITIS , MANY ALLERGIC CONDITIONS AND SKIN DISEASES ETC . If the couple before planning a child comes to us , then by proper councelling and right homoeopathic treatment we can fix the problem of bad genetic inheritance upto a significant percentage .
THIS QUESTIONNAIRE HAS MANY PARTS :
1. your present illness in detail.
2. your past illnesses. {Please take time to answer this part with the help of your
family members before coming to us.}
3. About all the parts of your body.
4. Deals with the factors that affect your health .{ Please think carefully about each of the factors mentioned and write what specific effects they have on you.}
5. About your mental state and your emotional nature { Please write in this part about your situation in life and about all the things that are bothering you. Be totally frank and open.}
6. About your sleep and dreams.
7. About your childhood, upbringing, deprivations or how you were as a child.
8. In this part you are given instructions on how to report each of your complaints. Read the instructions first. Then make a list of your complaints and describe each of them according to the instructions.
9.Photos depicting Front Face , Side Face , Video showing you laughing , moving , talking to someone , may be your mother ,spouse ,friend or some old videos of any function at home or outside.
PREVIOUS DISEASES & DRUGS USED
Every disease, poisoning, drug or accident leaves its mark and remains as a weak point in the system, much more than we can think of.
Homoeopathic treatment takes into account all these details of the past and removes all the weak points leaving your body strong and in harmony . Hence it is necessary for us to know about all the ailments you have suffered from in the past and the treatments you have taken. (be it ALLOPATHIC, AYURVEDIC, PRANIC HEALING etc.)
FACTORS THAT AFFECT YOU
Below are the list of things that you are exposed to, each of these factors may affect you in a particular way. Please write in what way you are affected by each of the following. Do you feel worse or better in any way from each of the factors. In what way do they affect you?
• For instance take the factor “sun”. Suppose by going in the sun you get a headache then write “Headache” opposite to “Sun”.
• Take another example if in hot weather you feel uneasy, then write “Uncomfortable “ opposite to “Hot Weather” in the column.
In this way write the effect of each factor on you. Especially write the effect each factor has on your main complaints.
• For instance if your main complaint is Asthma and this is worse
when lying on the back then opposite to “lying on the back” write “Asthma becomes worse”.
Sometimes one factor might make you feel worse in some respect, and better in some other respect.
• For instance cold air may cause headache but make you feel better in general. If this is so, please mention this difference clearl
MIND
• It is now universally acknowledged that your mind has tremendous influence on your body.
• For giving proper treatment it is absolutely necessary for us to understand your emotional and intellectual nature. We can thus treat you as a whole.
• In order to understand you , we will be asking certain questions. This information will help us much in giving you the correct remedy. Also such a remedy will help improve your mental make up.
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 headache”, “an eruption”, or “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, the pains are much less when lying down and covering up the head warmly and much worse when rising up, walking about or when the head becomes cool”, 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 and particular is your description of the symptoms.
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. Please use the figure on page 24 to indicate location.
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 which is cutting, burning
jerking, pressing. Express the sensation or pain as it feels to you.
WHAT MAKES YOU WORSE OR BETTER : Many factors are likely to influence your trouble.
Some factors may cause the trouble to increase and some factors may relieve the trouble. A
detailed list of the factors is given on pages 14 to 16. Please refer to them when describing
each of your troubles and indicate which factors make the complaint better or worse.
DISCHARGES : You may have a discharge from ulcers, fistula, eruptions the skin, lungs,
eyes, nose, ears, mouth, 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, increases or decreases ?
• 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 ?
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