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Advanced Case Analysis Form

Dr. Umang Chauhan — Safe • Natural • Root-Cause Treatment. Fill this form to get a personalized homoeopathic treatment plan.

1000+ Patients Treated Safe & Side-Effect Free Individual Case Analysis

Don't worry — everything you share is kept strictly confidential. Please answer openly so the doctor can understand your case fully.

1 Basic Details

Patient Name *

Age *

Gender *

Male Female Other

Marital Status

Occupation

City *

Contact Number *

2 Chief Complaint

What is your main complaint? *

Since when are you suffering?

Cause (if known)

Is your complaint

Increasing Decreasing Same

Location of problem

Type of sensation

What makes it better?

What makes it worse?

Time when symptoms are more

Morning Afternoon Evening Night

Any associated symptoms

3 Past History

Any major illness in the past?

Any surgery or hospitalization?

Do you have any of these?

Diabetes BP Thyroid Asthma TB

Are you taking any long-term medicines?

4 Family History

Family history of

Diabetes Hypertension Thyroid Cancer TB Mental illness

Any other family history

5 Physical Generals

Appetite

Normal Increased Decreased

Thirst

Low Normal High

Prefer to drink

Cold water Warm water

Thermal — body type

Hot patient Chilly patient

Food cravings

Sweet Salty Sour Spicy Milk Eggs

Food aversions

Perspiration

More Less Normal

Sleep quality

Good Disturbed

Sleep position

Dreams (if any)

Bowel habits

Normal Constipation Loose

Urine

Normal Burning Frequent

6 Mental & Emotional State

Nature

Calm Irritable Anxious Fearful Sad

Do you get angry easily?

Yes No

Do you keep emotions inside?

Yes No

Main stress factor in life

Memory

Good Weak

Company or alone?

Likes company Prefers alone

Any fears

6 For Female Patients

Age at first menses

Menses cycle

Regular Irregular

Flow

Scanty Normal Heavy Clots

Pain during menses

Before During After None

PMS symptoms

Leucorrhoea (colour / odour / itching)

Married since

Trying for pregnancy since

Any previous miscarriage / IUI / IVF

6 For Male Patients

Libido

Normal Low High

Semen analysis done?

Yes No

Any erectile dysfunction?

Yes No

Premature ejaculation?

Yes No

7 Personal History

Diet

Vegetarian Mixed

Exercise

Yes No

Addictions

Tobacco Alcohol Tea Coffee None

Sleep timing

8 Reports

Do you have any medical reports?

Yes No

If yes, attach your reports

File names are recorded with your case. Please also share the actual reports with the clinic on WhatsApp.

9 Expectation

What is your main goal from homoeopathic treatment? *

Doctor personally reviews your case Treatment customized for you

Your information is kept strictly confidential.