Case Form

 
Name * :
    Street Address
Location :
City :
State :
Country :
Pincode :
Work phone :
Home phone :
Fax :
Email* :
Url :
    Personal information
Date of birth :
Sex : Male Female
Height :
Weight :
Hair color :
Eye color :
Your present complaint * :
History of your past illness :
Family history of illness
(Eg:- Asthma, Cancer, Diabetes etc)
:
Nutritional status : Vegetarian Non-Vegetarian
Education :
Marital status and your relation with other members of family :
Addiction or habits if any :
Special desire for certain food articlesy
(salt, sugar, chilly, fish, meat etc)
:
Aversion to any food :
Stomach and abdomen
(acidity, flatulence, heart burn, colic or any other if present with details)
:
Please describe about your thirst
(increased or decreased, likes hot or cold water)
:
Chest
(if pain -details, the nature of pain and whether it is extending to some other place etc)
:
Respiration
(breathing difficulty, pain etc)
:
Urine
(troubles before during or after urination, force, if pain explain the nature of pain)
:
Stool
(constipation, diarrhea, nature of stool, flatulence, etc)
:
Sexual-male
(complaints in erection,emission etc)
:
Sexual-female
(history of abortion if any, types of previous labor, complaints in breasts, painful coition, cysts, fibroids etc)
:
Menses
(regular, irregular, nature of bleeding, pain, color of blood, clots if any etc)
:
White discharge(leucorrhoea)
(details if present)
:
Extrimities and joints :
Skin
(discoloration, warts, moles, eruptions, nails etc in detail)
:
Sleep
(position during sleep, snoring, mouth open during, talking or walking during sleep, dreams if any etc..) Your present complaint
:
Mind
(anxious, nervous, depressed, sensitive, weeping easily, sad, suspicious, religious,
fear, jealousy, ambitious, grief, introvert, silent or talkative, any strange,
peculiar feelings, hallucinations, your memory etc in minute details)
:
Physical
(which climate you like, like to be covered during sleep or not, feeling of coldness or heat
in body, any position that you are uncomfortable like standing, sitting, stooping etc;)
:
Sweat
(strong smelling, stains, discolouration)
:
Head
(headache, vertigo etc)
:
Hair
(dandruff, dryness, falling, greying etc)
:
Eyes
(discoloration, visual disorders , etc)
:
Ear
(discharge, hearing, peculiar sounds etc)
:
Nose
(block, cold, discharge, polyp, sneezing etc)
:
Mouth, Tongue
(aphthe, off -breath, coating on tongue etc )
:
Teeth, Tonsils, Gums :
Lymph nodes if any :
Medical reports :
Discharge diagnosis :
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