| CASE REFERENCE NO: |
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| DATE: |
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| DIAGNOSIS: |
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| NAME: |
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| LAST NAME: |
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| FATHER’S / MOTHER’S NAME: |
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| AGE: |
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| SEX: |
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| PRESENT WT. & HT: |
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| NATIONALITY: |
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| MARITAL STATUS: |
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| PROFESSION / OCCUPATION: |
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| ADDRESS: |
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| TELEPHONE: |
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| FAX NO: |
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| E-MAIL ADDRESS: |
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| PRESENT COMPLAINTS (MAIN COMPLAINTS): |
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ONSET
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| ORIGIN OR CAUSE OF EACH COMPLAINT: |
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| (PAST HISTORY (PREVIOUS DISEASES AND THEIR TREATMENT) |
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| FAMILY HISTORY (If any of your blood-relatives, i.e. parents, grandparents, siblings, aunts and uncles, suffer or have suffered in the past, from the following): |
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| Allergies: |
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| Eczema: |
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| Hay Fever: |
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| Sinusitis, Cold: |
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| Allergic Bronchitis: |
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| Asthma: |
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| Urticaria: |
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| Arthritis: |
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| Gout: |
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| Osteo-arthritis: |
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| Rheumatoid Arthritis: |
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| Cancer / Malignancy: |
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| Diabetes Mellitus: |
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| Hypertension: |
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| Coronary Artery Disease, Angina etc: |
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| Tuberculosis: |
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| Gonorrhoea / Syphilis or STD: |
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| Psychiatric & Mental Disorders: |
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| Schizophrenia |
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| Anxiety Neurosis / Depression: |
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| Any other sickness not mentioned above: |
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| PERSONAL HISTORY |
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| Kindly elaborate and mention habits, addictions like alcohol, smoking, tobacco etc. |
| Appetite: |
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| Are you vegetarian or non-vegetarian:? |
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| Do you consume eggs? |
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| Craving For Foods: |
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| Mention grades of preference +, ++ or +++. |
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| For example if you love sweets, mention + or ++ or +++ |
| Sweets: |
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| Salty food: |
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| Do you add Extra salt in your food?: |
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| Sour foods / pickles: |
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| Seasoned and spicy: |
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| Milk: |
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| Eggs: |
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| Fried and fatty food: |
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| Any other cravings in food? |
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| Do you dislike sweet or salty or any other specific food? |
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| How is your Digestion? |
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| Any complaints after eating? |
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Do you experience Fullness of the abdomen, Gas formation or Diarrhea after eating? Do you feel bloated, full and heavy after eating? |
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| Can you remain hungry for hours on end without food? Do you get irritable with hunger? |
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Does any item of food cause you discomfort, e.g. Acidity, Headache, Flatulence, etc. |
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| Thirst: |
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| How is your thirst, generally? Please mention the grade of thirst? If you are very thirsty, you may mention grades +, ++ or +++ |
| How much water do you drink at a time? |
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| How many times per day? |
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| Your preference in drinks: Please mention the degree of craving +, ++ or +++ |
| Would you prefer cold / chilled water or drinks even in the height of winter? |
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| Would you like your cup of tea or coffee piping hot? Or just normal warm? |
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| How many cups of tea / coffee do you generally drink in a day? |
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| Do you have any aversion to any drinks? |
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| GENERALITIES |
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| State how you are affected by or how you react to the following: |
| 1. Cold in general, cold air, drafts, cold winds, etc. |
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2. Do you like to cover your head (or wear a cap) when you go out in the cold or when exposed to a draft of cold air? |
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| 3. Warmth in general, warmth of bed or of room, external warmth like hot fomentation, etc. |
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| 4. Weather: Dry, Cold wet, Rains, Cloudy, etc. |
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| 5. Thunderstorms |
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| 6. Open fresh air |
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| 7. Near the sea / on mountains |
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| 8. Eating and Drinking (before, during and after) |
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| 9. Fasting |
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10. Any particular item of food / drinks which adversely affect you or make you sick |
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| 11. Closed, Crowded places, Elevators / Lifts, etc. |
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| 12. Exertion or Physical strain, Mental strain |
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| 13. Lack of sleep |
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| 14. In what part of 24 hours do you feel the best or the worst? |
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| 15. Do your troubles tend to occur or become worse, periodically (e.g. Daily or alternate days, every week, yearly, during new or full moon etc.) |
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STOOL / BOWEL MOVEMENTS |
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| Do you regularly have a satisfactory bowel evacuation? |
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| How many times do you move the bowels? When? |
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| Consistency: |
whether Well formed
Semi-formed
Very hard
Loose? |
| Odor: |
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| Color of stool: |
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| Any straining required for passing stools even though stools might not be hard or constipated? |
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| Any urgency for stools (e.g. Do you have to run for stool first
thing in the morning or immediately after eating? |
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| Any pain, burning, bleeding with stool? |
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| Piles / Fissure / Fistula? |
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Do you have flatus (wind) when passing stool and is the
stool noisy and spluttering? |
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| URINE |
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| Frequency, day and night: |
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| Any burning during urination? |
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| Any smell (Odor) in the urine? |
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| Any difficulty in passing urine? |
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Any difficulty in retaining urine? Do you have any incontinence while coughing or sneezing? Is the urine very urgent and you must rush immediately or it will escape? |
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| Any associated complaints with urination? |
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| FOR MEN |
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| Any complaints related to the reproductive system? Please give details. |
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| FOR WOMEN |
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| Any leucorrhoeal discharge? Itching, burning or discomfort associated? |
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| Any sense of ‘bearing down’ at the time of menses? |
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| PREGNANCIES |
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| How many times have you been pregnant? |
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| How many children do you have and what age are they? |
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| Did you have smooth pregnancies? |
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| Did you take any medication during pregnancy? |
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| Did you have normal deliveries? |
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| MENSES |
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| Age of appearance of first period (Menarche) |
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| How are the periods? |
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| What is the duration of your period and how many days cycle? |
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| How is the flow? – (scanty, heavy, clotted, any odor, color) |
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Any PMT (Pre-menstrual tension)? Do you have any complaints associated with, or before or after your menses? E.g. Moods, Headache, irritability, Anger, Weeping, Depression, Diarrhea or Constipation |
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| Any changes in your skin around menses? |
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| Any heaviness or pain in breasts before menses? Any nodules in the breast? |
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| MENOPAUSE: |
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| Age of menopause |
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| Any associated complaints at the time of menopause e.g. Hot flushes, Palpitation, Anxiety, Depression, etc. |
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| PERSPIRATION (SWEAT): |
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| Do you perspire a lot? |
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| Any particular part of the body that you perspire more on? |
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| Any strong / offensive odor associated (e.g. Sour smell) with your sweat? |
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| Does your perspiration stain your clothes or leave any salty deposits? |
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| SLEEP: |
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| Do you sleep well? |
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Any particular posture in which you lie the most when you sleep? E.g. Lying on the sides (right or left), back or on your abdomen, curled up, etc |
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| Do you feel refreshed after sleep? |
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| Do you dream while sleeping? |
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| Do you sleep-walk, sleep-talk, or grind your teeth in your sleep? |
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Any particular dream that is recalled and often repeated? (E.g. frightening dreams of falling from a height, or being pursued by some men, or dead people or relatives, etc.) |
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Do any of your complaints get worse or better, before, during or after sleep? E.g. Cough or asthma attack that wakes you up at night; migraine on waking in the morning; hot flushes just as you begin to fall asleep. |
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| SKIN: |
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Any skin problems that you have or had earlier? (E.g. allergies, eczema, fungal infections, pigmentations, acne, etc.) |
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Any itching or discoloration associated with it? |