Chinnamma Tina Belgaumkar DMS (HOMEOPATHY)

BELNA Homeopathy & Wellness centre FAMILY health clinic

Chinnamma Tina Belgaumkar DMS (HOMEOPATH)

“The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in diet, and in the cause and prevention of disease.”
Thomas Alva Edison

If you would like to consult the doctor, fill up the form given below and submit. Please make sure that you are filling the form with utmost care so that even the finest details may not be missed. Homeopathy relies on the minutest details of patients for the prescription.

Before filling the form, please send the brief details of your illness by e-mail to tbelgaumkar@hotmail.com, so that the physician can advise you about the possibilities of treatment with homeopathic medicines.

Name	:
Age	:
Sex	:
Marital Status	:
Occupation	:
Address	:
Phone No.	:
E-mail	:

Chief complaints

In the order of appearance with duration of each complaints

History of present illness

Explain in detail how the complaint started, progressed and the present state. Each complaint may be explained in the same way.

Past history

Any diseases which occurred in the past like tuberculosis, hepatitis, typhoid, arthritis, blood pressure, diabetes, HIV, cancer etc., may be described in detail in sequential order. Also specify any other diseases from childhood down to the present, chronologically with its nature, duration, severity, type of treatment undergone etc. in detail.

If Patient has undergone any surgical intervention for what and when

Family History

Detailed description of Father, Mother, Brothers, Sisters, Uncles, Aunts, Grand parents, Children with their age and any relevant diseases (Blood pressure, Diabetes, Hepatitis, Tuberculosis, Cancer, HIV Infection, Tumors, Arthritis, Skin diseases etc.)

Personal History

Specify life situation

(Mile stones and other developmental details in children)


Addictions	Tobacco	:	if yes quantity:
	Alcohol	:	if yes quantity:
	Drugs	:	Specify :

Patient as a person
Appetite	:
Thirst	:
Craving of any food items specify as salt ,sweets ,sour ,chills ,cold/hot etc	:
Aversion/ Allergy for any food items specify	:
Perspiration	:
Any parts specify	:
Offensive / Sour smell / Non Offensive	:

Urine	:
Pain / Smell	:
Type of pain / type of smell	:
Motion	:
No. of times /days	:
Thermal :
Climate which patient prefers	:
Takes bath in	:
Body feels warm / cold	:

For Females: Menstrual history
Menstrual flow for how many days	:
First Menstrual Period	:
Last Menstrual Period	:
Attained Menopause	:
Complaint associated with Menses	:	Before
	:	After
Leucorrhoea, its nature ,color ,constituency, before or after menses ,duration etc.	:

Obstetric, Gynecological (Menopausal) history in detail	:

Sexual History

	About sexual life. Any problems specify	:

Sleep : Nature, duration, position, dreams, snoring etc

Mind

Patients reaction towards the society, family and friends. Whether irritable, anxious, tensed, suspicious, likes company of friends, brooding, any suicidal thoughts etc.

Any other details may be added	:

For any other information please contact through E-mail : tbelgaumkar@hotmail.com