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CASE TAKING

Your Case taking starts as soon as the patient takes an appointment on the telephone and or as
soon as he enters your cabin so the physician must be vigilant enough (§ 83) in his observation of
the patient for :

1. Way of entering (Timid/ Bold; Fast /Slow)

2. Expressions (Smiling/Serious/Anxious/Sad/Cheerful/Shy)
3. The way Patient Greets you and leaves the clinic.

Preliminary Data:-
Name:-
Age:- Sex:-
Occupation :- Status:-
Religion:- Mother tongue:-
Address :- Contact no:-

C/C:-
Since when the complaints started
Onset - was Sudden or Gradual
Duration of the pain ,how long pain remains, how the pain comes and
goes,character of pain,extension of pain.
Which side first the complaint started Right or Left or it was from left to right
or right to left.
Is there any Cross wise affections e.g. Pain or any pathology in Upper left extremity
and Lower right Extremity only. Etc.
Modalities regarding the c/c.
Any investigations done for c/c.
In many Cases after noting the C/C the physician can come to know about the Speed
of patient and Remedy along with the miasm
Probable Diagnosis:-
H/O to rule out other disease

A/C:-

Past History:-Major illnesses which patient have suffered in the past.

In this try to elicit any major illness where in patient was not well after suffering from it.
E.g.:- Never well since the last attack of typhoid.
Any laser therapy done for calculi or as a corrective surgery for the eye,
Physical trauma.
In children ask for the history of vaccination and how did child reacted to it?
(for e.g. did child developed any physical or mental complaints like for e.g. complaints
of Fever/ Rash/ Convulsions/ Giddiness/ Headache/ Mental restlessness/ Shrieking/
Dullness/ Drowsiness, etc. try to see which system got affected after the vaccination if
there was A/F vaccination C.N.S / R.S / G.I.T / SKIN / General)
Also try to see after which emotions does the patient have fallen ill most of the time.
Try to find the journey of disease in chronological order and the
Ascending nature of the disease layer wise.
Trace the Progression of Psora → Sycosis → Syphilis.
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Family History :-Ask About hereditary illnesses in the family.

Gynaec/obs History :-
Ask about the menses in details.
Before, during, after menses any characteristic complaints.
Ask about menarche was on normal age or it was early or delayed menarche.
In menopausal woman ask the time of menopause normal--early--delayed.
In obs H/o:-was there any habitual abortions or miscarriages.

Drug History:-
In this ask to pt. is he taking any medications.
Any allergy to a particular drugs or medicine
In this one should think about any chronic side effects of the medications if patient is taking for
long period as the presenting complaints or associated complaints.

Investigations:-Here note down all the significant findings which the Patient has got done already
[recently] regarding his general health or about his complaints.

GENERALS:-
Appearance:- Built, Body structure, face, hairs, complexion, warts/moles/
frown on face, Discolouration or Pigmentation etc.
Appetite:-How is your appetite. Non veg/Veg.
Can you tolerate your hunger or not.
What kind of food you prefer warm or cold or anything is ok with you.
Drinks:-what you like soft drinks or fruit juices and how often you ask for
Lemonades/juices, etc.
Cravings & Aversion
Food/drink-agg/amel.
Thirst:-Ask how much water you drink in whole day; you feel thirsty i.e.
why you drink or as a habit you drink. or it is that you drink water during meals
only and you don't feel thirsty in between. Does your throat or mouth gets dry.
Prefer to drink cold/warm/room temperature water.
Perspiration:-try to find any pqrs regarding perspiration of the pt.
Stools
Urine
Thermals:-Ask pt. What can he tolerate more of heat or cold .
- Does he needs fan/A.C. all the time or he can be comfortable without it.
- Is he the first one to take sweaters or warm clothes or any covering in cold
atmosphere in the family.
Sleep:-Sound /Alert, restless and continuous tossing on bed in sleep,
prefers which position to sleep. Salivation during sleep. Catnap sleep.
Dreams:-good/bad, repeated dreams, related to family or his work.
Its affection in general
Speed: How is your speed of doing your work, while walking, while talking, while eating.
 Side:- In this elicit side of the patient,Try to see which side of patient is predominantly
affected from S/S ,any Mole, injury marks ,scars, any pigmentation from birth.
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SENSITIVITY in general:-
To sun.
To noise [slightest /loud, etc].
To light [Bright /yellow’ etc].
To tight clothing's [around neck; around abdomen].
To touch.
To perfumes/strong odors.
To Atmospheric Conditions e.g. Rains, cloudy weather, Moon, Winds, etc.
If anything is there then how the patient is getting affected .
Ask for any allergic reactions to metals or any synthetic products.
Senses:-Vision; Smell; Hearing; Taste; Extra Sensory Perceptions
Habits:- Ask the patient does he have any habits like smoking, drinking or
tobacco chewing.

MIND & LIFE SITUATION:-Start the conversation with asking with whom they are staying
presently .Is that they stay in a joint Family or a nuclear Family.

 Ask about education qualification: - if not studied than ask why they didn’t study or they had
interest but couldn’t study because of some problems or they were interested in something else.

Expressive or non expressive:-

i.e. Extrovert, Vivacious, loquacity, lamenting, Introvert, Reserved, Talk indisposed
to, quiet Disposition, Secretive.
- Expressive patients will start narrating their complaints as soon as they sit in front of you.
- Ask them that can they mix up easily in people around them.
- Do they love to talk and enjoy with people around them.
- Do they share their feelings with anyone?
Ask them what do they prefer to be in company or to be alone? & Why?

ntellect & Morals:-
Intellect is Quality which tells about the Thinking Capacity i.e. reasoning and understanding; to
comprehend and react to a particular situation of an individual.
- Ask how they were in their studies – used to study of their own or Always someone had to be
there behind them for their studies.
- To a businessman or an employee ask how they handle their work (in this try to see whether the
patient is intellectually sharp, Comprehension easy, Reading desires, Sharpness of
Mind or Slow, Idiocy, Mistakes makes many, Childish behaviour, Ideas deficient of,
Concentration Difficult, etc.)
- Ask how good are they in making Decisions (can they take decisions themselves on spot or do
they think a lot and then decide or is it that they have to take someone’s advice for their decision
or till end they are in confused state being Indecisive.)
Morals is concerned with the good and bad aspects (traits) of human characters in acceptance
to rules and standards of human behavior. For e.g. Good Morals like Anxiety conscience of;
Obedience; Obsequious; Reverence. Etc and Bad Morals like Insolence; Gambling; perversions;
Morals want of cruelty, etc.
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Also in this try to see whether the person sitting in front of you is Conscientious or
Non conscientious/ Diligent or Non diligent.
- Ask them whether they do their work/duty when they are not well? Why?
- In studies also were they very regular at school/college? Why?
-In Female’s ask they do their work inspite of their complaints? Why?

Memory:-Ask the patient how good is their Memory power
- can they easily recollect things of past very well
- how good are they in remembering numbers & names
- try to find any characteristics regarding the memory of the individual
(Here the Physician should try to see any peculiar thing about the Memory like Memory active or
any Forgetfulness tendency/ Weakness of Memory.)

Will:- [Faculty by which a person decides on and initiates action]

Will of a person can be elicited by asking the individuals what their reaction is in a crisis and also
trying to find out what measures do they take to avoid those crisis.
Ask them that can they handle any Responsibilities given to them alone any time.
- How confident are they in handling things alone.
- If something critical happens at home how do they deal with that situation
- Are they capable of handling situations Alone or their output is much secured
with some Support.(Support, want of)
- Ask them if any Injustice or something wrong is happening in front of them than what they do
or how do they react to it (Injustice cannot tolerate).
(Here try to see whether the person is Strong Willed, Confident, Courageous,
Self-dependent, Optimistic, Perseverance, Positivity or weak willed, Dependent,
Timid, Pessimist, Bashful, Embarrassment, cowardice, etc)

Nature or Disposition: -
Angry/ Mild, Yielding/Weeping, Haughty/Timid/Sarcastic/Contemptuous,
Apprehensive/Fearful, Loquacious/Quiet, Contented or Discontented, Quarrelsome/
Fighter/ Revolter/Indifferent, etc.
- Ask them about their nature with people around them.
- Does he is more on angry side or towards calmer side.
- Whenever they get angry how they behave with those who are in front of them.
- Which is the thing or act which they can’t tolerate in their surroundings?
- Anger is Expressed or Suppressed
( If expressed then in which way verbally/ Physically, etc)
- Can they express their anger in front of everyone i.e even to their elders.
- Ask with whom so they got angry they will keep their relations with them.
- Do they keep thinking on the issue for which they got angry?
- Can they forgive those people who have hurt them or they will keep grudges for them.
- Will they take revenge when offended?
- Ask them how are they seen as a person in their society; Image amongst their friends;
- Image amongst the colleagues; Image amongst the relatives ?

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Sensitivity:- To Rudeness/Criticism/Relations/Social position/Money/Admonition/

Appreciation/Ego/Injustice, etc.
- Ask what is their reaction when someone talks / speaks to them Rudely or arrogantly
- Ask how do they React when someone points out or criticizes in their work.
(In this try to see the reaction of the individual like they get anger or feel hurt)
- Same way try to find out how do they get affected or are sensitive to Relations/
Social position/Money /Ego/admonition/Injustice, etc.

Emotional:-
I.e. Sentimental, Grief, Sympathy, Affectionate, Rage, Jealousy, etc.
- Ask them their reaction whenever anything happens against their wish or will.
- Ask about their emotional sensitivity.
- Do they help person who come to them for help or they themselves go to the
needy person.
- Are they very much involved in charity work? Why?
- Do they get easily affected when they see someone in pain in front of them,
If Yes than what is their reaction?

 Anticipation /Apprehension i.e. Anxiety:-

- Here ask patient if any new work is said to them or something which is new for them asked to
be done how confident are they in accepting that work & what thoughts come to them.
- If you are supposed to reach at a place at a given time than do you reach on time or Get late or
reach before the time only.
- If you are told that some guests are coming at your place so how do you manage.
In anxiety try to see exactly for which thing the patient is more worried of eg.
Anxiety health
Anxiety children
Anxiety family
Anxiety for others
Anxiety of future
Anxiety trifles about
Anxiety anticipating engagement
Anxiety salvation
Anxiety conscience –it is a feeling of Guilt conscience or feeling where one blames themselves
for some Sin or bad thing happened (or can happen in future) to others because of them.
Attachment:-
- Ask whom are they most attached to.
- Ask them which is the most important thing for them in their life e.g. Career, Family,
Friends, Business, Name & Fame, Money, etc
- Ask them whenever they are ill or not feeling well and people around them like family member’s
or relative’s & Friends ask about their Health then what do they feel?
(Consolation, Sympathy Desires or aggravates).
- If any family member for e.g. anyone of the parents or siblings or children gets unwell then how
do they react? Do they show concern and worry or it doesn’t affects much (Ask this question to
the accompanying person with the Patient) Try to see how much he/she is affectionate/
caring/ concern/Indifference to their loved one’s.
Fears:-Ask about the fears.
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Childhood History: - Here one should ask about the whole childhood nature and Experiences or
interests, etc. in detail. For e.g.:
- Esp. nature as a child from 0-6 years of age?
- What kind of child you were accounted as for e.g. Mild, silent, fearful, timid, weeping, reserved,
introvert, extrovert, cranky, angry, obstinate, mischievous, destructive, obedient, studious,
yielding, etc.( ask for incidences to deduce such traits)
- Which qualities of your childhood days are remembered by your parents and relatives?
- When he/she went to school first time how was the reaction?
- When guests would come to home how would be his/her reaction?
- Reaction with other children in surrounding?
- Which qualities of childhood are still remembered by you?
- Image in school amongst teachers?
- Reaction before exams.
- Was he daring in acts and sports activities?
[Please ask for life incidences to get one’s disposition and original traits.]

Try to elicit how the patient is mentally Sensitive to:

Behaviour of others: Rudeness, Criticism, Reproach, Contradiction.
Surroundings: Music, Nature, Cleanliness, Religion, Animals.
Self: Health, Money, Ego, Honor, Work, Discipline, Position, Success, Failures.
Relationships: Attachments with Family, Friends, Bonds.

But the most important thing which a physician can never forget in whole case is the Cause of the
Disease i.e. A/F which should be elicited by skillful conversation with the patient.
To take A/F as the prescriptive or the entry point in the case one should see to it that Cause
should be Recent and Related.

So one should keep in mind that for a psoric disease the cause has to be a psoric e.g.
Psoric causes:
Irritability, anger, hurt, mild, grief
Anxiety, worry, anticipation
Angry when obliged to answer
Sensitivity (Rudeness, criticism, neglect external impression, disharmony & Quarrels, joy, light,
noise, music, odour, touch, pain).

For a Sycotic illness in a patient the cause has to be Sycotic e.g.

Sycotic causes:
Sensitive to slow and stressful, prolonged stress
Prolonged grief, vexation, stress
Brooding disappointment in love
Anger suppressed, mortification, after long domination
Nursing the sick
Grief from loss of money / position, loved ones
Business cares / house cares

And similarly if the patient is in Syphilitic Disease the cause has to be Syphilitic e.g.
Syphilitic causes:
Violent, strong and destructive sudden
Shock, insult, humiliation, abuse
Honour wounded
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Sudden anger, rage

Fright, panic
Strong anger suppressed
Sudden loss of loved ones
Sudden joy
Sudden loss in business, money, prestige
Drugs and suppressions in general
Physical trauma

But one should keep in mind that if patient gives you any h/o of any cause for his ill health in past
so one should correlate it with the disease miasmatically.
If miasm has bloomed then the cause is not important.(footnote 120).

After Listening or taking the whole case don’t rely completely on patient.
Carefully Observe your Patient for
- How was he talking to you?
- How was he answering your questions?
- What was the quality of speech?
- How were the expressions of the patient about their sufferings during whole conversations?

Never totally belief the patient blindly try to see whether the person sitting opposite to you is a
Honest/Liar/Boaster/Manipulative while taking the case, cross examine your Patient.

There are many certain things which one cannot forget to make their note of while taking the case
themselves about the patient by the physician e.g.
- Jesting.
- Affectation.(Artificial behaviour)
- Bashful.
- Naiveness.
- Cautious.
- Coquettish/Flirting.
- Buoyancy
- Censorious/Critical
- Sarcastic.
- Restlessness/Hyperactivity/Hurried Nature.
- Effeminate/Mannish behavior.
- Graceful.
- Obsequious.
- Gestures.
- Lamenting.
- Begging.
- Clinging.
- Frivolous.
- Inciting.
- Crank.
- Shameless.
- Foppish.
- Vanity.
- Loquacity.
- Talking speed
- Attention Seeking or Playing Antic’s.
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- Self-esteem or Ego.
- The way patient laughs or talks.
- The way Patient Sits in front of you.

Some Emotional Causes And Life Events Affecting Different Age Group:
In Age Group From Infants To Toddlers:
- Fear or Fright out of a sudden fall or scolded by someone; toddler getting afraid of new people or
suddenly someone shouting at them; Child was exposed to something new for the first time esp.
some religious Rituals or any procession where lot of people and noise scared him.
- Child is frequently exposed to Parent’s Quarrels or Discords.
- Mother of the child being subjected to harassments from In laws in front of the child.
[Child seeing mother weeping very often may develop feeling of insecurity and Grief]
- Discords among other Family members happening at home in front of the child.
- Witnessing domestic violence is terrifying to children and emotionally abusive. Even if the mother
does her best to protect her children and keeps them from being physically abused, the situation
is still extremely damaging mentally for the children.
- Mother is a working female so resumes for her job: Mother who was looking after her Child for 1st
few months after the birth of the baby resumes her Job.
- Child is kept away from mother because mother having some chronic infectious disease
recurrently falling ill or mother has some mental illness where she is unable to take care of
the child.
- In between parents went for 1 or 2 days leaving the child with the Grandparents or with the
Relatives.
- Childs Basic demands being neglected by the parents or by the caretaker of the child
(demands may be for adequate food, attention, clothing, to play, to go out, hygiene, etc.)
- Child got frightened by seeing or coming in contact with any pet animals like dog, cat, etc.
- Sibling jealousy: New born sibling in the family.

Amongst School Going Children:

- Sibling jealousy
- Punishment in school
- Child Loosing rank in class.
- Being neglected amongst friends.
- Being compared with the siblings or other children by parent’s or other family members.
- Humiliation in class from the teacher.
- Domination from the parents or any other family member.
- Parent’s Quarrels or Discords, missing working parents.
- Failing in studies.
- Failure in any extracurricular activity- for e.g. not being selected in team or for any other group
activity, disappointment in cultural activity.
- Feeling Discriminated in the class by some teachers
- Child living with an alcoholic or addict Father is very difficult and can easily lead to abuse and
neglect of the child.
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There are other certain small things which happen very often with most of the school going children
but how does the child react to such events are not noticed by many of us which is very important
for us to ask in Childhood history for e.g.
- Constant belittling, shaming, and humiliating a child.
- Calling names and making negative comparisons to others.
- Telling a child he or she is ―no good," "worthless," "bad," or "a mistake."
- Frequent yelling, threatening, or bullying.
- Ignoring or rejecting a child as punishment, giving him or her the silent treatment.
- Limited physical contact with the child—no hugs, kisses, or other signs of affection.
- Exposing the child to violence or the abuse of others, whether it be the abuse of a parent,
a sibling, or even a pet.

Amongst College Students:

- Failure in getting to the desired career.
- Problems with friends.
- Disappointment in love.
- Failure in studies.
- Inferiority complex about money, status, looks, clothes, etc.
- Sexual abuse.

Amongst Middle Age:

- Financial loss; Financial stress.
- Problems at the working place - Falling short of capabilities as compared to other colleagues,
injustice or certain discrimination by the superiors or the colleagues, working against the will,
Physical or sexual abuse [esp. for working females].
- Marital relationship [extra marital affairs]
- Couple not conceiving.
- Social embarrassment for [e.g. someone did wrong in family for which the Police came
to the house for the first time so the person felt it was better if he would not have
been alive to see such incidence; Son or Daughter marrying to intercaste spouse]
- In joint family again feeling of Discrimination by the superior of the family in
comparison to other members.

Note: Proforma for case taking is not a hard and fast rule to take a case in this pattern
only. Our aim is to get the Genetic Constitutional Similimum of which the first step is a
good case taking which should be developed as an art by each & every Predictive
Homoeopath.
The questions and verbal communication here used are simply indicative, being intentional
to provide certain data. The whole of the above Guidelines is just suggestive.
It is not intended that the patient be limited to the language or symptoms of the proforma.

© Copyright 2009 PREDICTIVE HOMOEOPATHY PVT. LTD.

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