Chapter 7.1–7.2: The case history chart. Questions guide the practitioner and prod memory so as not to forget anything important.
The Importance of Listening
As we listen to patients' problems, it is important to listen to the unspoken information, the tone of their voice, their body language, and the emotions behind the voice. In this interaction, things are not always as they seem. In some difficult cases, it can take about five sessions to actually see the real problem.
Male patients may come with backache as their complaint when their main problem is impotence. Patients come for hay fever and forget to mention ulcerative colitis. Patients feel safe giving a physical complaint even though it appears in the presence of an emotional state.
Principle
"In energy-balancing treatments, the diagnosis is half the treatment — because we decide the points accordingly."
10-Question Case History
Work through the 10 question categories. Check findings as you go.
Main Complaint
Detailed description and history of the complaint (may be more than one)
Medication
Currently taken medication Past medication (steroids, HRT, cancer medication)
Patient & Family History
Past illnesses Surgery Accidents
Sleep
When and how long do you sleep? Sleep quality? How do you feel when waking?
Hot or Cold
Do you freeze or get hot easily? In which area of body? What weather do you prefer?
Sweating
Do you sweat easily or excessively? Much or little? In which situation? Are you hot or cold when sweating? Night sweating?
Hunger, Appetite & Thirst
How often do you need to eat? Can you go long hours without eating? What time of day are you most hungry? How large are your portions? How is your energy when hungry? After eating? What do you eat most? How much do you drink? Preferred temperature for food and drink? Strong liking for any flavours?
Stools & Urine
How frequent is your stool? What is the consistency? Colour? Any pain or bloating? Where? If diarrhoea — caused by food or nervousness? If constipated — do you use laxatives? How often? What helps? How many times a day do you pass urine? How many times at night? Usual quantity? Usual colour? Any problems with urination?
Menstruation
Are you on contraceptives? Why? Do you use an IUD? Are you taking HRT? Why? How long? How long is your cycle? Is there any pain? When during the cycle? Duration of bleeding? Quantity? Colour? Clots?
Leucorrhoea
Colour and smell?
Reflect
What did the 10-question history reveal about your organ system? Which question surfaced an answer you hadn't connected before?