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ONLINE HOMOEOPATHIC TREATMENT
Homoeopathy
Fill this form and send to us
Please Write your detail sign & Symptom, current complain or you can use separately sheet
(copy it and pest in your word pad and write carefully in a detail and send it to us by email deoshlok@gmail.com ,
1.Name --------------
2.Address------------
3. City---------------
4.Country---------------
5.Phone---------------
6 Mobile---------------
7.Email ---------------
8.Age-
9.Male/Female---------------
10.Weight---------------
11.Height---------------
12.What are you doing at present................................
13..Single/Married/Separated/Divorced/Widow/widower---------------
14.Describe your current complain---------------
What exactly is happening ?
How do you feel ?
How does this affect you ?
How does it feel like ?
. What comes to your mind ?
. One situation that had a big effect
on you ?
. How did that feel like ?
. What sensation do you experience in
that situation ?
. What are you showing by that gesture of your hand.(habits or Action) ?
15.Describe your Past complain/Any surgery-
16.Write your pathological report (Blood test Ultra sonography / MIR/ X-ray, if any (optional) if any.--------------..
17.High Blood Pressure Continue from and current B.P.---------------
18.If any heart Disease
19 Name of medicine using currently-------
20.If Diabetic Patient/Name of medicine---------------
21.Insulin Dependent/Doses---------------
22.Detail about Operation/Surgery if any ---------------
23.Thyroid Problem if any T3/T4/TSH---------------
24.Female
a Any Gynecology Problem (Write in Detail)
b. Is there is any pain in the Breast before menses---------------
c. Is there is any Tumor/Fibroid/ in Breast/Uterus---------------
d. Is there is White discharge (Leucorrhoea)---------------
e. Is there is pain during mating------------------
f. Is there is habit of Masturbation----------------
g. About Your sexual desire increased/absent/normal---------
h. Is there is any itching/scratching of your gyneic area--------
i. Flow of your menses-------------
25. Male
a. Is there is any infection/ulceration/eruption on your pubis
b. is there is any seminal discharge during stool
c. Is there is any discharge during talking from female
d. Is there is any itching/scratching on groin region
e. About Your sexual desire increased/absent/normal---------
26.Gastritis---------------
27.Joints pain---------------
28.Swelling---------------
29.Any Other Disease---------------
30. About Your sexual desire increased/absent/normal--------------
31.Choose your nature from following word ---------------
Mental Symptoms:-(Compulsory)-Morose, Quarrelsome, Hasty, Lachrymose, Anxious, Delirious, Groping, Despairing, Sad, Hopeful, Fearful, Restless, Calm, Drowsy, dullness, Anger, Being overwhelmed, Depression and gloom Despair and faithlessness , Despondency from overwork, Domination of others, Doubt or Discouragement, Easy impressionability, Fear and Shyness, Fear for the others welfare, Fear of losing mental balance, Feeling of powerlessness, Guilty and self-blame, Hard master onto oneself with an urge to inspire others, Hopelessness, Immaturity of Mind/Emotions, failure to learn from mistakes impatience, indecision in difference or boredom Intolerance and criticism lack of mental tranquility, lack of motivation and incentive longing for past happiness, nostsliqia, low self-confidence, Mental Fatigue, Mental torture or worry, Mental/emotional and physical weariness, Overcome for welfare of others, Overenthsiasm, Pride or aloofness, Resentment and bitterness, Sadness, greif, shock, Self centered talkativeness, Self-distrust, Shame or feelings of un cleanliness, Terror, jealousy, Weakness too willing , Fear from known thing, fear from unknown thing.
32.(in case of married) Is there your husband/Wife is cooperating to you or not any friction write in detail------------------
33. What is your current anxiety in your mind (compulsory)- Write in detail--------------
34. How you will be deference from other person or What is your peculiarity in nature--------------
35. Can you give speech to the public meeting-------------
Photographs of the
current Disease can be sent by email separately on
Contact us:
E-mail deoshlok@gmail.com , deoshlok@sancharnet.in
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