| Name* |
|
| Age |
|
| Sex |
|
| Marital Status |
|
| Occupation |
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| Address |
|
| Email* |
|
|
| Chief Complaints |
|
| If the case is
already diagnosed then diagnosis of the case |
|
|
If
investigations done, reports of investigations |
|
| Under any
medication, if yes specify. |
|
|
| Present History |
|
| Whether patient
is suffering from any diseases like Arthritis, Blood
Pressure, Diabetes, HIV, Tuberculosis Or cancer specify
since when |
|
| Past History |
|
| Any diseases
which occurred in the past Tuberculosis, Hepatitis, Typhoid
etc. any others specify when |
|
|
If Patient
has undergone any surgical intervention for what and when |
|
| Family History |
|
| Family history
of any diseases (for Father, Mother, Brother, Sister) Blood
pressure, Diabetes Mellitus, Hepatitis, Tuberculosis,
Cancer, HIV Infection etc. any others specify Arthritis |
|
|
If married
– about children. Any diseases specify |
|
|
| Patient's Nature |
|
| Appetite |
|
| Craving for any
food or drinks specify |
|
|
Aversion
for any food items |
|
| Thirst |
|
| Perspiration |
|
| Any parts
specify |
|
|
Offensive
smell |
|
| Urine |
|
| Pain |
|
| If yes type of
pain specify, before/after/during |
|
| Bowel Motion |
|
| No. of times
/days |
|
| Thermal
: |
|
| Climate – which
patient prefers |
|
| Takes bath in |
|
|
Addictions |
Tobacco |
|
if yes-Quantity
|
| Alcohol |
|
if yes-Quantity
|
| Drugs |
|
if yes-Quantity
|
| For Females |
|
| Menstrual flow
for how many days: |
|
| First Menstrual
Period |
|
| Last Menstrual
Period |
|
| Attained
Menopause |
|
|
Complaint associated with Menses |
Before |
|
| During |
|
| After |
|
| Leucorrhoea |
|
|
Sexual History |
| About sexual
life. Any problems specify |
|
| About fertility.
if any problems |
|
| |
|
| Mental
Features of the patient |
|
| Any other problems, specify |
|
|
| |
|
|
Biochemistry Report |
|
| |
|
| Fasting Sugar |
|
| Random Sugar |
|
| Urea |
|
| Creatinine |
|
| Uric Acid |
|
| Total Bilirubin |
|
| Direct Bilirubin |
|
| Indirect Bilirubin |
|
| SGOT (AST) |
|
| SGPT (ALT) |
|
| Alk Phosphatase |
|
| Acid Phosphatase |
|
| Amylase |
|
| Total Protien |
|
| Albumin |
|
| Globulin |
|
| Total Cholesterol |
|
| HDL Cholesterol |
|
| LDL Cholesterol |
|
| Triglycerides |
|
| Calcium |
|
| Phosphorus |
|
| LDH |
|
| CPK |
|
| Electrolytes - Sodium |
|
| Potassium |
|
| CSF |
|
| Protien |
|
| Sugar |
|
| Thyroid function test |
|
| |
|
|
| Blood R/E |
|
| Total Count |
|
| WBC |
|
| RBC |
|
| Platelets |
|
| Differential Count |
|
| Poly |
|
| Lymph |
|
| Eosino |
|
| Mono |
|
| Baso |
|
|
| Haemoglobin |
` |
| ESR |
|
| |
|
|
Urine R/E |
|
|
Colour |
|
|
Reaction |
|
|
Albumin |
|
|
Sugar |
|
|
M/E |
|
|
Pus cells |
|
|
RBC |
|
|
Epithelial
Cells |
|
|
Crystals and
Casts |
|
| |
|
|
Semen Analysis |
|
| |
|
|
pH |
|
|
Viscosity |
|
|
Liquefaction |
|
|
Volume |
|
| Motility |
|
|
Count |
|
|
Morphology |
|
| |
|
|
Any other investigation, specify |
|
| |
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|
Please type the characters you see in the picture |
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