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PERSONAL INFORMATION
Regd. Case No: Consultant:
Name: Age:
Sex: Address:
Education: Religion:
Occupation:
Past:   Present:
Phone No:
Residence: Office:
Mobile:
E-Mail Address:
Required

 
Chief Complaint
FAMILY INFORMATION
Father Name:  
Live/Dead: Age:
Mother Name:
Live/Dead: Age:
CHIEF COMPLAINTS
DIAGNOSIS:
Location(Place of complaint):
Sensation:
Modality: In which condition symptoms are increased or decreased?
Concomitant: Any symptom along with main symptom
PATIENT AS PERSON
GENERAL APPEARANCE:
Built: Posture:
Speech: Height:
Gait:
DIET:
Appetite/Hunger: How many times you take meal?
Thirst: You like cold water or hot water and how much quantity of water you take daily?
Desire: Abnormal craving to any article of food, sugar, salt etc.
Aversion: Abnormal aversion to any article of food, sugar, salt etc.
Food/Drinks (aggravation & amelioration)
How do you feel after eating and drinking?
DISCHARGE:
Stool: What is the character and colour of stool, any smell from stool?
Urine: How do you pass urine?
What is the colour of urine, any smell from urine?
Perspiration: On which body parts sweating is more, any smell and staining to cloths?
Abnormal Discharges:
THERMAL STATUS:
Season: Which season you like more?
Foods/Drinks: Do you like hot food/drinks or cold?
Covering: Do you like covering the body or not?    
Bath : Do you like bathing or not?
If you like bathing then what  type of water do you prefer for bathing hot/cold?
REACTION:
Time/Periodicity: Height/Altitude:
Light: Motion:
Noise: Music:
Sun: Draft:
Season: Weather:
Position: Hot/Cold:
Travel - Air Sickness: Travel - Vehicle Sickness:
Travel - Sea Sickness:
LOVES AND HATES:
Heat and Cold; Sensation of heat and desire for cold. Lack of vital heat.
Motion and Rest: Open Air:
Sex:
AGGRAVATION AND AMELIORATION: (complaints are increased or decreased)
Air, Heat and Cold, Motion and Rest:
Sex, Food, Special senses:
MENSTRUAL HISTORY:
First menstrual period: In which age first menses started?
Last menstrual period: The date of last menses?
Discharge: Which type of blood is comes out, any clots with blood flow?
Complaints: Any complaint - Before menses
Complaints: Any complaint - After menses
Complaints: Any complaint - During menses
LEUCORRHOEA: (white discharge from the vagina)
Discharge: What is the color of discharge, any smell of discharge, any irritation and burning due to discharge?
Concomitants: (Any complaint with discharge) - Before
Concomitants: (Any complaint with discharge) - After
Concomitants: (Any complaint with discharge) - During
CLIMACTERIC HISTORY
Any complaint started after first menses:
OBSTETRICAL HISTORY
How many children do you have?
How many years after marriage first child born, gap between them?
Any complication during: Pregnancy
Any complication during: Labour
Any complication :
Any complication during Breast feeding:
Details of the medication:
CONTRACEPTIVE HISTORY:
CONTRACEPTIVE HISTORY(IF ANY):
SEXUAL FUNCTIONS:
How is your sexual life? Any physical or mental problem due to sex?
CHILD HOOD HISTORY
Birth: Birth Weight:
Congenital/Genetic/Infectious disease: History Medication:
Father’s History: Mother’s History: - Before Pregnancy
Mother’s History:  - During Pregnancy Mother’s History:  - After Pregnancy
Lactation:-Breast fed Lactation:- Bottle fed
Weaning: Milestones -Mental
Milestones - Physical Vaccination:
Allergies: Tendencies:
Teeth Grinding/Salivation/ Nocturnal Enuresis: Worms:
Night Terrors:
FAMILY HISTORY
Any complaint or disease in the members of the family? Such as - diabetes, cancer, asthma etc. (In both maternal and paternal side):
PAST HISTORY
Give details about the diseases you suffered from, from childhood till now:
TREATMENT HISTORY
Give details of the medicine you take now for any disease?
Details about treatment you have already taken:
SLEEPS & DREAMS
How is your sleep during day and night?
Moan, talk or cry out in sleep?
Start during sleep?
Do you snore? If so - during inspiration? or expiration?
On which side do you prefer to sleep on the back, left or right?
Do you cover yours self well up, or can not bear clothes on your self?
Are you disturb during sleep or have a sound sleep?
Are you disturb during sleep or have a sound sleep?
Any dreams during sleep?
ALLERGIC HISTORY
Are you allergy to any thing (such as dust, any substance or particular weather etc.)?
HABITS
Any particular habit? e.g., Nail biting, Hiding, Stealing, etc.
HISTORY OF SURGERY
Post-operative condition:
LIFE SITUATION
Detail about your work and family circumstances :
(Childhood-domination/fright/grief, Adolescence- Ambitions/ disappointment in life, Relations with family/ friends/ relatives, Happy/ sad incidences, any particular up and downs in family.)
  MENTALS
Please give detailed description regarding following mental symptoms:
(Sensitive, Imagination, Constructive thinker, Delicacy, Brilliant, Conscientious, Stability, Happy-go-lucky, Good Leader, Optimistic, High Spirited, Frivolous, Business Minded, Positivity, Industrious, Ambitious, Determined, Powerful, Ruthless, Affability, Animation, Buoyancy, Censorious, Complaining, Contrary, Cosmopolitan, Cheerfulness, Defiant Disputations, Elated, Exhilaration, Enthusiasm, Euphoria, Excitement, Familiarity, Fraternized, Hypochondriac, Impatient, Impetuous, Jovial/Jesting, Lamenting, Ludicrous, Sociability, Vivacious, Absent-minded, Bashful, Contemptuous, Egotism, Embittered, Ennui, Tedium, Estranged, Exclusive, Haughty, Introvert, Loathing, Misanthropy, Sulky, Timidity, Torpor, Trance, Wicked, Courageous, Audacity, Positive, Obstinacy, Perseverance, Pertinacity, Plans, Timidity, Bashful, Irresolution/Weak willed, Wavering, Hesitating, Spineless/Loss of will, Fearful, Cautious, Indifference, No Control over will, Persists in nothing, Undertakes many things, Initiative lack of, Conscientious, Anxiety, Neglected his duty/Wrong done, Carefulness, Cautious, Moral affections want of, Sensitivity want of,  Unfeeling/Unsympathetic, Wicked, Joy on misfortune of others, Cut others desire to, Intellectual, Witty, Thoughtful, Thought, Rapid, Quick, Thinking faster, Artistic aptitude for, Activity, Creative.)
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