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1. Patient Identification
Patient Name *
Age *
Sex *
Date *
Contact No. (WhatsApp ID) *
Occupation
Marital Status
Address
Education
Referred by
Chief Concern / Reason for Consultation *
2. Chief Complaints & Detailed Characteristics
Complaints Summary
Side (Location)
Select side
Right
Left
Both / Bilateral
Depth
Select depth
Superficial
Deep
Sensation / Character
Select character sensation
Burning
Stitching
Throbbing
Pressing
Tightness
Cramping
Cutting
Tearing
Shooting
Numbness
Heaviness
Itching
Rawness
Pulsation
Fullness
Onset
Select onset
Sudden
Gradual
Intensity (0-10 Scale)
Progression
Select progression
Getting better
Getting worse
Unchanged
Comes and goes
3. Modalities
What makes complaint WORSE? (Time / Position / Motion)
Morning
Evening
Night
After midnight
Standing
Sitting
Lying
Movement / Motion
Cold air
Warm room
What makes complaint BETTER?
Rest
Movement
Pressure
Warmth
Cold application
Fresh air
Lying down
Eating
4 & 5. Concomitants & Causation
Concomitant Symptoms
Physical Causes / Triggers
Injury / Surgery
Infection
Exposure to cold
Heat exposure
Change of weather
Overexertion
Lack of sleep
Dietary change
Emotional Causes / Triggers
Grief / Bereavement
Fright / Fear
Anger / Vexation
Humiliation
Disappointment
Financial stress
6-8. History (Present, Treatment, Past Medical)
History of Present Illness & Evolution
Treatment History
Past Medical History
Asthma / Allergies
Diabetes
Hypertension
Thyroid disease
Skin disease
Migraine
Heart disease
Tuberculosis
9-15. Family History & Physical Generals
Family History (Hereditary Risks)
Diabetes
Hypertension
Cancer
Tuberculosis
Asthma / Allergy
Heart disease
Appetite
Select appetite
Good
Poor
Increased
Variable
Thirst
Select thirst
Very little
Moderate
Large quantities
No thirst despite dryness
Strong Food Desires
Sweet
Salt
Sour
Spicy
Fatty foods
Cold drinks
Bowel Habits (Stool)
Select stool consistency
Hard
Soft
Loose
Watery
Mucous
Sleep Quality
Select sleep quality
Deep
Light
Restless
Interrupted
16-21. Thermal State, Perspiration & Mental State
Thermal State *
Select Thermal
Chilly
Hot
Neither / Neutral
Perspiration Amount
Select amount
Scanty
Moderate
Profuse
Social Behaviour & Personality Traits
Sociable
Reserved
Prefers solitude
Sensitive to criticism
Perfectionistic
Independent
Mental / Emotional History & Stress Response
22-27. Lifestyle, Substance & Allergies
Work Shift Pattern
Select work shift
Day shift
Night shift
Rotating
Stress Level (0-10)
Tobacco Use
No
Yes
Alcohol Use
No
Yes
Allergies & Sensitivities
28-33. Physical Exam, Investigations, Totality
Patient Physical Build
Select build
Lean
Average
Obese
Muscular
Referral Required
No
Yes
Physical Examination & Vitals
Totality of Symptoms & Homoeopathic Analysis
34. Prescription Record & Remedies
Add Remedy
35. Next Follow-up Date *
Save Case Proforma & Sync Portal
Patient Directory & Unified Profile
Patient Profile
Total Sessions
Latest Follow-up
Actions
Complete Consultation History Log (All Fields)
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