Sample Case Sheet

For efficient treatment procedure, patients are requested to send along filled up patient information sheet.

Download a copy of Patient Information Sheet in word document form which can be filled and mailed to maharaja@maharajawellness.com

Date 
Patient Personal Details
Name 
Full Postal Address 
Country 
Religion 
Telephone number 
Mobile number 
E-mail id 
Date of Birth 
Age  
Sex 
Guardian name and Contact number 
Occupation & Nature of work 
Marital Status (Single, Married, Divorced, Widowed) 
Referred by (how did you come to know about me and MaharajaWellness)

Presenting Problems
 (Use the client’s own words as much as possible)

What are the different Signs & Symptoms of the client? 
 
What is the area of the problem
 
Please describe the exact nature of the problem including sensations

Factors changing the complaint

(In relation to)

 

How is complaint changing with respect to Time?
How is complaint changing with respect to Rest?
How is complaint changing with respect to Motion?
How is complaint changing with respect to Temperature?
How is complaint changing with respect to Weather?
How is complaint changing with respect to Bathing?
How is complaint changing with respect to Position? Standing, sitting, lying down?
How is complaint changing with respect to Pressure?
How is complaint changing with respect to Noise?
How is complaint changing with respect to Eating specific foods?
How is complaint changing with respect to different Habits?
How is complaint changing with respect to Sleep?
How is complaint changing with respect to Menstruation?
How is complaint changing with respect to Sweat?
How is complaint changing with respect to Vomiting?
How is complaint changing with respect to Urine?
How is complaint changing with respect to Bowel movement?
How is complaint changing with respect to Coitus?
How is complaint changing with respect to Anger?
How is complaint changing with respect to Fear?
How is complaint changing with respect to Grief?
How is complaint changing with respect to Consolation?
How is complaint changing with respect to New moon?
How is complaint changing with respect to Full moon?
How is complaint changing with respect to Local application?
How is complaint changing with respect to Other external circumstances?

When the problem began
(Chronological order of the problems)

 

Course of the problem

(Changes in respect to)

 

What are the Physical aspects of the problem?
What are the Mental aspects of the problem?
What are the Emotional aspects of the problem?
What are the Career aspects of the problem?
What are the Environmental aspects of the problem?
What are the Economic aspects of the problem?
What are the Nutritional aspects of the problem?

Probable Cause of the problem

(Causes & Events precipitating in respect to)

 

Physical aspects.
Mental aspects
Emotional aspects
Career aspects
Environmental aspects
Economic aspects
Nutritional aspects
What according to you has caused the problems?

Duration of the problem
(Date of starting till recovery or chronic)

Treatments taken for the problem

Type of treatment taken
Duration of the treatment
Nature of treatment
Medications
Other health modalities undertaken

Core issue identification
(to be done by the therapist)

(will be done according to the case needs)

Chakra method
EET method
Corrective therapy method
Paris Window method
Aura photograph diagnosis

Head to Foot Scanning of symptoms
(Include as much as details as possible. Apart from the suggested complaints if any other signs or symptoms are present, please make a note of them too.)

Head complaints

(Any complaints of)

Headache
Migraine
Perspiration
Vertigo
Burning
Any other sign or symptom
 

Eye complaints

(Any complaints of)

Vision
Pain
Burning
Lachrymation
Any other abnormal sign or symptom
 

Ear complaints

(Any complaints of)

Hearing
Discharges
Colour & odour of discharges
Pain
Any other abnormal sign or symptom
 

Nose complaints

(Any complaints of)

Nose block
Sneezing
Difficulty in breathing
Nasal discharges
Sneezing
Irritation
Burning
Any other abnormal sign or symptom
 

Mouth complaints

(Any complaints of)

Odour
Salivation
Taste
Ulcers
Toothache
Grinding of teeth
Swollen gums
Bleeding gums
Any other abnormal sign or symptom
 

Throat complaints

(Any complaints of)

Pain
Mucous
Irritation
Burning
Swelling
Obstruction
Any other abnormal sign or symptom
 

Chest complaints

(Any complaints of)

Cough
Pain
Heaviness
Obstruction
Breathing difficulty
Expectoration
Palpitations
Discomfort
Any other abnormal sign or symptom
 

Abdomen & Nourishment complaints

(Any complaints of)

Distension
Swelling
Mass
Burning
Irritation
Acidity
Appetite
Desire
Favourite taste
Aversion
Intolerance
Thirst
Eructation
Nausea
Vomiting
Any other abnormal sign or symptom
 

Bowel & Rectum complaints

(Any complaints of stool)

Of nature
Colour
Character
Odour
Urging
Frequency
Evacuation
Constipation
Diarrhoea
Pain
Burning
Irritation
Mucous
Bleeding
Discomfort
Piles
Fistula
Any other abnormal sign or symptom
 

Urine complaints

(Any complaints of)

Nature
Colour
Character of urine
Sediment
Odour
Quantity
Bleeding
Burning
Discomfort
Urge
Frequency
Any other abnormal sign or symptom
 

Perspiration complaints

(Any complaints of)

Nature
Colour
Staining
Odour
Discomfort
Quantity
Location
Any other abnormal sign or symptom
 

Back & Extremities complaints

(Any complaints of)

Pain
Stiffness
Injury
Cramps
Restricted movement
Sound in movement
Any other abnormal sign or symptom
 

Hair, Nails, & Skin complaints

(Any complaints of)

Hair fall
Discoloration
Brittleness
Dryness
Oily
Discharge
Colour
Odour
Warts
Moles
Itching
Any other abnormal sign or symptom
 

Reproductive system complaints

(Any complaints of)

Sexual desire
Night fall
Masturbation
Menstruation
Clotting
Odour
Discharge
Ulcer
Injury
Bleeding
Any other abnormal sign or symptom
 

Sleep complaints

(Any complaints of)

Duration
Quality
Sleep hygiene
Frequency
Insomnia
Sleepiness
Tiredness
Dreams
Disorder
Sleep walking
Enuresis
Any other abnormal sign or symptom
 
Past history
(Information regarding past illnesses, hospitalizations, accidents, etc.)
 

Obstetric history

Number of children
Their gender
Year of childbirth
Nature of childbirth
 

Personal history

Do you have Habits of smoke?
Do you consume alcohol, if yes, how much, how frequently and what Alcohol do you consume?
Do you consume Tobacco, if yes, what form, and how much in a day?
Do you have any other Addictions?
What is your Diet type?
How is your Personal hygiene?
Do you have any Allergies?
Do you have any Disease tendencies?
How is your general Activity level?
How is your General built?
Height
Weight
What are your Hobbies?
What are your Fun and leisure activities?
Describe your Level of peace with self, others and life.
Describe your Level of fulfilment.
 

Treatment History

History of treatment underwent for current & previous illnesses
Type
Duration
Medications taken
 

Family History

(Medical history of family members including)

Parents
Siblings
Grandparents
Immediate uncles & aunts
Number of family members
Family atmosphere
Relationship with family members
Spouse
Family dynamics
 

Social interaction

Do you believe you are dependent on others for your needs?
Do you always ask help from others for solving your problems?
Do you adhere to others opinion and wishes to avoid confrontation?
Do you sacrifice your needs for the welfare of others?
Do you have fear that something wrong may happen in your life?
Do you feel your emotional and other needs are not met by others?
Do you feel others may abandon you or you may lose someone in a close relationship?
Do you have a fear that others may abuse you?
Do you feel there are lots of defects in you?
Do you feel difficulty in trusting others?
Do you feel different from the society where you live in?
Do you feel you are not socially attractive and that the society does not feels you are good enough?
Do you feel shame, embarrassment or self-conscious in presence of others?
Positions held with society
Relationship with others
General opinion about the society
Level of social interaction
Any other important information
 

Career growth

Describe the Details of current job.
Describe about your Previous jobs.
Describe about your Place of work.
Describe about your Nature of work.
Describe about your Satisfaction at work. What are the things in your work that give you a feeling of satisfaction?
What are the Growth opportunities at work you have?
Describe about your Relationship with others at workplace.
Describe about your Job environment.
Describe about your Needs at workplace.
Describe about your Ideal work conditions.
Describe about any Stress at workplace.
 

Mental Generals

What are the major thought patterns you focus on?
What are your major belief systems?
How much importance do you give for your achievements?
How good is your memory?
How strong will power do you have? Are you able to achieve things which you want to achieve?
How well are you able to understand stuff and things in life?
Do you have a good orientation about self?
Do you have a good orientation with Others?
Do you have a good orientation with Time & place?
How good is your intellect?
What are your major goals?
How good is your comprehension
How good is your concentration?
How good is your temperament?
Do you have any issues with speech?
How much caring person are you?
Do you have any anxiety?
Do you have any guilt?
Any other abnormal symptom
 

Emotional generals

What are your major & minor values in life?
What are your major Emotional affiliations?
What do you feel most of the time?
Do you get anger? What triggers you to anger?
Do you have any Fear of poverty?
Do you have Fear of criticism?
Do you have Fear of ill-health?
Do you have Fear of loss of love of someone?
Do you have Fear of old age?
Do you have Fear of death?
Do you have Fear of unknown?
Do you have Any other fear?
What is your Happiness level?
What is your Sadness level?
Describe the most Happiest event in your life.
Describe the most Saddest event in your life.
How much is your Satisfaction level? What are the things which cause you satisfaction?
What are the things which cause you Dissatisfaction?
How much are you comfortable with Emotional expression?
Do you have Aggression issues?
How much is your Assertiveness level?
Do you have any Avoidance behaviour or thoughts or feelings?
Do you have any feelings of Helplessness?
What has been a Depressing moment in your life?
What has been a Memorable moment in your life?
Describe about your Personality.
Are you Introverted?
Are you Extroverted?
How is your General mood.
Any other abnormal symptom.
 

Environmental generals

What is the Environmental scenario at residence?
What is the Environmental scenario Place of work?
What is the Environmental scenario General places of visit?
What is the Environmental scenario Commute? 
 

Economic generals

What is your Socio-economic status?
Describe about your Desired economic lifestyle?
Describe your Relationship with money.
Describe your Association with money.

Life span development
(Major incidents which happened in terms of milestones, trauma, normal development, school life, college life, work, at the life spans of;

 

Prenatal
Infancy (0-2 years), (relationship with mother & parenting)
Early childhood (2-4 years), (relationship with mother & parenting)
Middle childhood (4-7 years), (relationship with parent of opposite sex, teacher & group)
Late childhood (7-12 years), (relationship with teachers, peers, parents)
Adolescence (13-24 years), (relationship with peers)
Early adulthood (25-35 years), (relationship with spouse)
Middle adulthood (35-60 years), (relationship with spouse & children)
Late adulthood (60 onwards), (relationship with spouse, children & grand children)
 
Are you at peace with your life?
Is there anything that disturbs you a lot?
What is your opinion about various treatments methods which are offered by me or MaharajaWellness?
What are your views about metaphysical methods of treatment and treatment methods which are not accepted by the scientific world?
Do you have any questions that you want to ask?
Did you go through relevant sections in the website and blog concerned with your condition and needs? If not, please contact me through email for the links to be provided.
Any other information to be shared.
 
Guidelines to the patient
 
Therapy plan
 
Follow-ups Suggested
(Follow ups may vary for patient depending upon their condition.)
First follow up: 2 weeks from date of consultation.
Second follow up: 4 weeks from date of consultation.
Third follow up: 6 weeks from date of consultation.
Fourth follow up: 3 months from consultation.
Fifth follow up: 6 months from consultation.
Sixth follow up: 9 months from consultation.
Seventh follow up: 1 year from consultation.
 
Next appointment fixed on
 
Follow up questions
How has your health progressed from the last consultation?
What are your current health issues you will like to discuss about?
What are the obstacles you are facing in becoming healthier and happier?
This is a sample case sheet. Actual history taking may differ for individual patients depending upon the condition and treatment methodology. Patients can have a copy of their case sheet on request.
Be Healthier and Happier. Become Empowered and Enriched.
Dr Maharaja SivaSubramanian N

 

Be Healthier and Happier. Become Empowered and Enriched.

Dr Maharaja SivaSubramanian N

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Dr Maharaja SivaSubramanian N is India’s 1st Holistic Concierge Medicine Doctor specializing in Homoeopathy, Counselling, Hypnotherapy, Nutrition, Exercise Therapy. Contact Dr Maharaja N for your treatment needs.