1. Always describe complaints:

• From the beginning (for self, those requiring help, or young patients)
• State just how they began
• Note any changes since that time

2. Mention all previous illnesses and give a complete history of your health i.e.:

• Skin diseases
• Children’s diseases
• After-effects of illness
• Fevers, colds, flu’s, sores, ulcers
• Severe Injuries:
• Their location and type
• What treatment was used?

3. Mention all medical treatments that have been used in the past.

• Please note the year or age

4. Describe all mental of “nervous” feelings and conditions, such as:

Likes Desires Critical Confused Hurried Feeling Lack of interest Mental dullness

Dislikes Fears Timidity Discouraged Persistent thoughts Overly conscientious Hard to concentrate

Moody Irritable Absentminded Discontent

1. Are You Startled By: Noise?   Being touched?   From sleep?   When falling asleep?
2. Do you like or dislike business or work?
3. Feel better or worse from mental work?
4. Feel better from physical exertion?
5. Is noise, the talk of others annoying?
6. Is the crying of children annoying?
7. Are you easily affected by bad news?
8. Sensitive to offense or contradiction?
9. How do you feel about the future?
10. How affected by friends & relatives?
11. Prefer company or feel better alone?
12. Like or dislike a room full of people?
13. Any recent or past emotional shocks, frights, or disappointments?

5. Describe your appetite.

• Small, large or changeable?
• Food & drinks you prefer, and make you feel better or worse afterward.
• Include salt, sweets, fats, sour, spicy, eggs, meat, vegetables etc.
• Drink a lot, little or not thirsty?
• Foods & drinks you dislike.
• Prefer hot, cold, or warm food & drink?

6. Do your symptoms remain the same? Change character or shift around?

7. Pain Description: *

How does it feel?	Ache or pressure?
Is it constant?	Does it change?
Is it periodical?	Does it wander?
Go up or down?	Go out or across?
Go right to left?	Go left to right?
Slow/quick to heal	Quick/slow onset

8. What Makes You Better or Worse?

Day or night?	Sleep?	Seasons?
Month?	Motion?	Rest?

8. How Do Weather Types Affect You?

Cold and dry	Cold and humid
Hot and dry	Hot and humid
Rainy	Snowy
Frosty	Thunderstorm
Cloudy	At the seashore
Low Altitude	High Altitude

10. Sensations are important. Note:

Type

Location

Time of day

• What makes it better or worse?
• Tell all sensations however slight or peculiar e.g.: it feels “as if”.

11. Describe skin, scalp or nail problems

Location	Color	Dry
Moist	Thick	Thin
Scaly	Crippled	Pimply
Discharge	Warts	Growths
Appearance	Burn	Itch

· Is area better or worse by scratching?

· Do heat, a warm bed or room, cold, wool, exercise, warm or cool water help?

· Do you have varicose, spider or large veins?

12. Describe all discharges:

Small amount	Large amount	Color
Gluey/sticky	Thick	Thin
Time of day	Becomes red	Odor
Color of stains	Becomes raw	Burns

Notice what helps or worsens your symptoms.

13. Describe Urinary Symptoms of:

Frequency	Sudden urge
Pain: after	Kidney pain
Pain: before	Pain: during
Urine sediment	Urine color
Urethra pain	Bladder pain
Lose urine	Slow stream
Prostatitis	Sugar in urine

14. Describe Bowel Symptoms:

Rectal spasms	No urge for BM
Hemorrhoids	Incomplete stools
Stool recedes	Difficult stool
Diarrhea	Urge w/o results

Stool Description:

Color	Odor	Hard
Dry	Large	Small
Narrow	Pasty	Bloody
Frothy	Slimy	Thin
Watery	Flat	Pappy

• Note anything unusual.

15. Female Symptoms:

Age menses began	Regular cycle
Pain location & type:	Irregular cycle
Pain to back/groin/thigh?	Clotted?

• Describe the type of pain (See No. 7*):
• What helps or makes the pain worse?
• Childbearing history: miscarriages, live births, C-sections, etc.
• Your health before, during and after menses?
• Is there sexual desire or aversion?
• Is intercourse normal, or painful?
• Vaginal discharge or eruption?
• Any itching, or burning or vaginal area?

16. Male Symptoms:

• Note any abnormality of Male Organs.
• Is there any pain, itching, burning, perspiration, or skin eruptions?
• Is intercourse satisfactory etc.?
• Are there nightly emissions?
• Is sexual desire/performance normal?

17. How Do You Feel From The Effects of:

• Hot, warm or cold temperatures?
• Hot, warm, or cold bathing?
• Does moving or lying down feel better?
• Are you better or worse from perspiring?
• Are you tired, weak or weary?
• How does exercise affect you?

18. Similia Similibus Currentur:

(Let Likes Be Cured By Likes) implies strict individualization.

• In other words, the curative remedy is the one that produced in healthy human beings, symptoms most similar to those, which distinguish the patient from all others suffering from the same ailment.
• They are the more striking, singular, uncommon, and peculiar symptoms—because they are more notable and remarkable; singular because they are unique, strange, unusual and therefore distinctive.
• These symptoms are characteristic and peculiar because they belong to an individual, and to the remedy that cures.
• They are uncommon because as they are seldom found in other individuals or in the pathogenesis of other remedies.

Judith J. Pruzzo-Hawkins,
R.Ph., C.C.H.

101 S. Coit Rd., Suite 317
Richardson, TX 75080-5715
Tel. 972-479-0400 X 322
Fax 972-479-9435

E-mail: jjpruzzo@johnsonmedicalassociates.com
www.johnsonmedicalassociates.com
www.judithjpruzzohomeopathy.com
Initial: 5/03/Rev: 6/06: jjph