Homeopathic treatments at Dr. N.K. Jain for Hair loss, Psoriasis, Acne, Alopecia, Asthma, Vitiligo, etc. Start Homeopathic treatment
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   Online Treatment  

Our on-line homoeopathy treatment offers a specially designed program, which includes the following aspects:

  • In-depth case study: Collection of patient's case-details and case history through a specially designed questionnaire by e-mail.

  • Analysis and evaluation of the case-details, once received, by a team of specialists consisting of
    (a.) Homoeopathic doctors
    (b.) Various consultants on panel.

  • Homoeopathic medicines : The medicines will be sent to you through post or courier.

  • The patients would be followed up online when required.

  • Complete evaluation of the case after a definite period of therapy.

  • The patient must be agreed to the terms of use.



Please fill in this questionnaire in as great detail as possible.  Things that you might feel are "medically not relevant" can give important information, such as your habits, patterns of behaviors, moods etc.  So please report such things fully.  Include any strange feelings and sensations that you think might be important, even if they are not specifically asked for in the questionnaire.  Such information might give helpful information about your individual reaction to the illness, and thus help us prescribe the best medication for your problem.  Of particular importance are changes that you have noticed recently, in appetite, in desire or aversion for particular foods, in behaviors, sleep patterns, bowel habits, dreams etc., so please report any such details that you have noticed.

  Name :  
  Age :  
  Email :  
  Sex :  
  Occupation :  
  Address :  
  Contact No :  

Present Complaints :


  Addiction :-
(Any abnormal Sensation)
(Normal & Forget Fullness, or Impaired)
  Desire :  
  Aversion :  
  Pulse :  
  Height :  
  Weight :  
  Urine :  

(a) How is your appetite?

(b) Is there a tendency to indulge in particular kinds of foods
(eg: sweets, sour foods, salty foods, etc.)

(c) Are you allergic or sensitive to any foods?

(d) What kind of weather are you most comfortable in?
(Summers, humid weather, winter)

(e) Are you particularly uncomfortable in any weather or climate?

(f) Do you sweat at all?
If you do, where do you sweat noticeably? (Scalp, upper lip, under arms, back, chest, etc.)
Under what circumstances?
(While eating, under tension, when you physically exert yourself etc.)

(g) In general do you like being out in the open air or do you feel more comfortable in closed rooms?

(i) Do you dream at all? If you do, do you remember them? What is the content?
(eg: daily events, falling into space, running after a train, etc.)

(j) How is the quality of your sleep most of the time? (Rested and refreshed, feel tired most mornings etc.)

(k) How is your bowel habit?
(Regular, constipated, diarrhea etc.) Is it modified by anxiety? By diet (eg. spicy food causes diarrhea)?

(l) How is your liquid intake?
(Feel thirsty all the time, fairly normal etc.)

(m) How would you describe yourself? (Amiable, a loner, quite social, a tendency to be very picky about things like cleanliness and keeping appointments etc.)

(n) How do you react to stress and tension? (Tend to be verbally expressive, tend to keep things to yourself and brood about them, etc.)

Going all the way back to paternal and maternal grandparents.  (Allergies, skin problems, asthma, Alzheimer's, migraines, any other neurological disorders, heart problems, cancers, mental disorders, etc.


Mother   Father  
Maternal Grand Father   Grand Father  
Maternal Grand Mother   Grand Mother  
Maternal Uncle   uncle  
Maternal Aunt   Sister  
Maternal Sister   Brother  

Additional Information(if any)


Age at onset of periods?
Periods? (Regular/Irregular) Regular    Irregular
Physical symptoms preceding the onset of periods (eg: heaviness/pain in the breasts, changes in moods, changes in appetite, changes in bowel habit, backache, pain in the legs, headaches, dreams etc.)?
Duration and interval between periods (eg: bleeding last for 3-5 days and the interval between periods is 27 days)?
Any discharge before/during/after periods? Before    During    After
Number of children and whether the deliveries were normal? Any post-delivery problems? Were the children breastfed or not? Any problems during the breastfeeding phase? Any abortions? Any complications after abortions?
Age of onset of menopause?
Did the periods cease gradually or abruptly? Gradually    Abruptly



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