Forms

CASE REFERENCE NO:

DATE:

DIAGNOSIS:

NAME:

LAST NAME:

FATHER’S / MOTHER’S NAME:

AGE:

SEX:

PRESENT WT. & HT:

NATIONALITY:

MARITAL STATUS:

PROFESSION / OCCUPATION:

ADDRESS:

TELEPHONE:

FAX NO:

E-MAIL ADDRESS:

PRESENT COMPLAINTS (MAIN COMPLAINTS):

1.

2.

3.

4.

5.

ONSET

ORIGIN OR CAUSE OF EACH COMPLAINT:

(PAST HISTORY (PREVIOUS DISEASES AND THEIR TREATMENT)

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):

Allergies:

Eczema:

Hay Fever:

Sinusitis, Cold:

Allergic Bronchitis:

Asthma:

Urticaria:

Arthritis:

Gout:

Osteo-arthritis:

Rheumatoid Arthritis:

Cancer / Malignancy:

Diabetes Mellitus:

Hypertension:

Coronary Artery Disease, Angina etc:

Tuberculosis:

Gonorrhoea / Syphilis or STD:

Psychiatric & Mental Disorders:

Schizophrenia

Anxiety Neurosis / Depression:

Any other sickness not mentioned above:

PERSONAL HISTORY

Kindly elaborate and mention habits, addictions like alcohol, smoking, tobacco etc.

Appetite:

Are you vegetarian or non-vegetarian:?

Do you consume eggs?

Yes No

Craving For Foods:

Mention grades of preference +, ++ or +++.

For example if you love sweets, mention + or ++ or +++

Sweets:

Salty food:

Do you add Extra salt in your food?:

Sour foods / pickles:

Seasoned and spicy:

Milk:

Eggs:

Fried and fatty food:

Any other cravings in food?

Do you dislike sweet or salty or any other specific food?

How is your Digestion?

Any complaints after eating?

Yes No

Do you experience Fullness of the abdomen, Gas formation or Diarrhea after eating? Do you feel bloated, full and heavy after eating?

Yes No

Can you remain hungry for hours on end without food? Do you get irritable with hunger?

Yes No

Does any item of food cause you discomfort, e.g. Acidity, Headache, Flatulence, etc.

Yes No

Thirst:

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?

How many times per day?

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?

Yes No

Would you like your cup of tea or coffee piping hot? Or just normal warm?

How many cups of tea / coffee do you generally drink in a day?

Do you have any aversion to any drinks?

GENERALITIES

State how you are affected by or how you react to the following:

1. Cold in general, cold air, drafts, cold winds, etc.

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?

3. Warmth in general, warmth of bed or of room, external warmth like hot fomentation, etc.

4. Weather: Dry, Cold wet, Rains, Cloudy, etc.

5. Thunderstorms

6. Open fresh air

7. Near the sea / on mountains

8. Eating and Drinking (before, during and after)

9. Fasting

10. Any particular item of food / drinks which adversely affect you or make you sick

11. Closed, Crowded places, Elevators / Lifts, etc.

12. Exertion or Physical strain, Mental strain

13. Lack of sleep

14. In what part of 24 hours do you feel the best or the worst?

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.)

STOOL / BOWEL MOVEMENTS

Do you regularly have a satisfactory bowel evacuation?

Yes No

How many times do you move the bowels? When?

Consistency:

whether Well formed Semi-formed Very hard Loose?

Odor:

Color of stool:

Any straining required for passing stools even though stools might not be hard or constipated?

Yes No

Any urgency for stools (e.g. Do you have to run for stool first thing in the morning or immediately after eating?

Any pain, burning, bleeding with stool?

Yes No

Piles / Fissure / Fistula?

Do you have flatus (wind) when passing stool and is the stool noisy and spluttering?

URINE

Frequency, day and night:

Any burning during urination?

Any smell (Odor) in the urine?

Any difficulty in passing urine?

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?

Any associated complaints with urination?

FOR MEN

Any complaints related to the reproductive system? Please give details.

FOR WOMEN

Any leucorrhoeal discharge? Itching, burning or discomfort associated?

Any sense of ‘bearing down’ at the time of menses?

PREGNANCIES

How many times have you been pregnant?

How many children do you have and what age are they?

Did you have smooth pregnancies?

Did you take any medication during pregnancy?

Did you have normal deliveries?

MENSES

Age of appearance of first period (Menarche)

How are the periods?

Regular Irregular

What is the duration of your period and how many days cycle?

How is the flow? – (scanty, heavy, clotted, any odor, color)

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

Any changes in your skin around menses?

Any heaviness or pain in breasts before menses? Any nodules in the breast?

MENOPAUSE:

Age of menopause

Any associated complaints at the time of menopause e.g. Hot flushes, Palpitation, Anxiety, Depression, etc.

PERSPIRATION (SWEAT):

Do you perspire a lot?

Any particular part of the body that you perspire more on?

Any strong / offensive odor associated (e.g. Sour smell) with your sweat?

Does your perspiration stain your clothes or leave any salty deposits?

SLEEP:

Do you sleep well?

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

Do you feel refreshed after sleep?

Do you dream while sleeping?

Do you sleep-walk, sleep-talk, or grind your teeth in your sleep?

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.)

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.

SKIN:

Any skin problems that you have or had earlier? (E.g. allergies, eczema, fungal infections, pigmentations, acne, etc.)

Any itching or discoloration associated with it?