Forms

Thank you for your interest in EDDE HOMEOPATHY MEDIC. In order to understand your needs and enhance our value added services, please provide us with the following details. Your kind feedback is our priority and much appreciated.

To order Treatment services : Send back enquiries via the below forms:-
Send in payment for consultation and medicine after obtain feedback on charges and instruction of payment by the attended doctor.

    Your Name (required)

    Gender

    Age

    Phone

    Your Email (required)

    Address

    Occupation

    Height

    Weight

    Chest

    Married

    If Yes, Spouse Name

    Present Complaints

    When is the signs and symptoms of the present complaints appear first ?

    Which is the side more affected ?

    Appearance of the affected parts

    When is the disease felt more, time ?

    Feeling of relief comes by

    GENERALITIES

    Complexion

    Head

    Nose

    Lips

    Nails

    Taste

    Neck

    Abdomen

    Face

    Forehead

    Cheeks

    Ears

    Appetite

    Tongue

    Stools

    Scalp

    Eyes

    Hair

    Skin

    Thirst

    Throat

    Urine

    Others

    Anxious , worried, cheerful, sad, shy , etc ?

    Memory : Thoughts :

    Bad habits, if any?

    Mild, yielding or irritable, quarrelsome, jealous, etc.:

    Liking/disliking for sweat/ saltish Chilly/Hot:

    Liking/disliking for cold/warm food

    Liking/disliking for cold/warm drinks

    What type of season suits best?

    Which type of season is uncomfortable?

    Which type of season/climate aggravates the disease?

    Whether likes to remain in closed room or in open air, even if the cold open air?

    Any kind of discharge ( indicate either thick, thin, white, yellow, bloody, green, blue, Etc) ?

    History of any previous illness?

    History of TB, Cancer, etc in the family ?

    ( both maternal / paternal ) ?

    ( both maternal / paternal ) ?

    ADDITIONAL INFORMATION TO BE GIVEN BY THE FEMALE PATIENTS
    Menses:

    (a) When appeared first?

    (b) Any complaint since then ?

    (c) Present position:

    (d) Are they painful and how the pain is relieved ?

    (e) What is its colour ? Bright red, dark, brown, black, clotted, etc ?

    (f) Complaints during, before and after menses, if any ?

    (g) When does it flow more ?

    (h) How long it remains ?

    Leucorrhoea :

    (a) Whether thick or thin ?

    (b) Bland or acrid ?

    (c) Cold or hot (d) Colour ?

    (d) When does it flow more ?

    Any other information, such as any complaint since last delivery, painful coitus, sexual desire, etc ?


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