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?

YesNo

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?

YesNo

YesNo

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

YesNo

YesNo

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.

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

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?

YesNo

How many times do you move the bowels? When?

Consistency:

whether Well formedSemi-formedVery hardLoose?

Odor:

Color of stool:

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

YesNo

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?

YesNo

Piles / Fissure / Fistula?

URINE

Frequency, day and night:

Any burning during urination?

Any smell (Odor) in the urine?

Any difficulty in passing urine?

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?

RegularIrregular

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

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

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?

Do you feel refreshed after sleep?

Do you dream while sleeping?

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

SKIN:

Any treatment taken for the skin? Its details:

Any complaints or abnormality of the nails or skin around the nails?

Any complaints of hair falling, early graying, dandruff, thinning, etc.?

Any warts, moles, birth marks on the body?

Does your skin heal normally after an injury or takes very long to heal?

Any tendency to form excessive scar tissue (Keloids)?

Any tendency for wounds to suppurate (form pus easily)?

THE MIND:

(It is very important to give as much details as possible in this section of the Pro forma especially in the case of Chronic Diseases)

Have you become or are-

Suspicious, doubting

Offended easily (cannot take any criticism)

Are you critical of others, always finding faults

Irritable, quarrelsome, violent, etc.

Depressed easily, sad, gloomy

Timid / Shy / Bashful

Jealous or Suspicious

Anxious, restless, nervous or excitable

Are you silent, quiet, reserved or talkative? Do you make friends easily?

Are you very affectionate? Do you demand love and warmth from others?

Do you cry easily? What makes you cry (grief of others, music, kind words of affection, etc.)?

How do you stand and react to contradictions?

How is your memory, power of concentration and mental ability?

PREVIOUS TREATMENT TAKEN

Disease Medicine Prescribed System of Therapeutics

INVESTIGATIONS

LABORATORY TESTS

X-RAY, CT-SCANS, MRI, others

Name:

Address:

Phone:

E-mail:

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