* Your Name :
* Occupation :
* Age :
* Sex :
* Address :
* Phone :
* Date of Birth :
* BP :
* Pulse :
* Height :
* Weight :
* Married/Unmarried/Widow :
* Your E-mail :
CHIEF COMPLAINT (Please write a brief account of your present problems and information about how long you have had th.em (in chronological order) e.g.: Difficulty in breathing started in__ after being out in the cold for__days.) :
When did this problem begin?
What happened in your life around that time?
What do u think cause it?
Factors which tend to either increase or decrease the intensity of your symptom (certain types of foods or weather, any time of day or night, movement, light, noise, heat/cold, or anything else that you can think of
Any other accompanying complaints-
Any investigations reports-
What medications are you taking at present?
What medications are you taking at present? OTHER COMPLAINTS Describe here all other troubles you might be having or have in the past experienced. Each should be described fully as suggested above for the 'Chief Complaint'.
Going all the way back to paternal and maternal grandparents- (Allergies, skin problems, asthma, Alzheimer's, migraines, any other neurological disorders, heart problems, cancers, mental disorders, etc. For example, "Elder sister has/had eczema, paternal aunt died because of complications of heart disorders; maternal grandma had Alzheimer's," etc.
PAST HISTORY: Major illnesses suffered in the past? (As far as you can remember) whether your delivery was normal or caesarian, whether there is a history of neonatal jaundice, measles, mumps, typhoid etc. Any effects of vaccinations like fevers, loose bowels, frequency of colds, running nose, coughs.
Milestones of life (as far as you can recollect): teething, trying to sit up, walking, talking, etc. (on time, delayed, early).
History of broken bones, accidents, head injuries, dog/insect bites etc.
Have you had any surgery? What and when?
Have you had at anytime warts, cysts, tumors, polyps, etc (mention where, when, how treated)
(a) How is your appetite? Veg/Non veg. Can you tolerate your hunger or not. What kind of food you prefer warm or cold or anything is ok with you
(b) Is there a tendency to indulge in particular kinds of foods?
(c) Are you allergic or sensitive to any foods?
(d) How is your liquid intake? How much water you drink in a whole day; you feel thirsty i.e. why you drink or as a habit you drink. Or it is that you drink water during meals only and you don't feel thirsty in between. Does your throat or mouth get dry, Prefer to drink cold/warm/room temperature water.
(e) How is your bowel habit? (Regular, constipated, diarrhea etc.) Is it modified by anxiety? By diet (e.g. spicy food causes diarrhea)?
(f) What kind of weather are you most comfortable in? (Summers, humid weather, winter) What can you tolerate more of heat or cold. Do you need fan/ A.C. all the time or can be comfortable without it. Are you the first one to take sweaters or any covering in cold in the family? Are you particularly uncomfortable in any weather or climate?
(g) In general do you like being out in the open air or do you feel more comfortable in closed rooms?
(h) Do you sweat at all? If you do, where do you sweat noticeably? (Scalp, upper lip, under arms, back, chest, etc.) Under what circumstances? (While eating, under tension, when you physically exert yourself etc.)
(i) Do you dream at all? If you do, do you remember them? What is the content? (e.g.: good/bad, daily events, falling into space, running after a train, dead people, etc.)
(j) How is the quality of your sleep most of the time? (Rested and refreshed, feel tired most mornings, Sound/Alert, restless and continuous tossing on bed in sleep, prefers which position to sleep, salivation during sleep, catnap sleep, etc.) Do you do anything during sleep? (Speak, laugh, shriek, walk, grind your teeth, snore, have your mouth or eyes open)
(k) Do you have any habits like smoking or drinking or tobacco chewing?
(l) How is your tongue? Clean/coated
(m) Any change of taste you feel in mouth?
(n) Additional Information (if any)
FAMILY AND CURRENT SITUATIONS
Whom are you staying presently with? Do you stay in a joint family or a nuclear family?
Give a clear cut picture of your relationships with the family members, friends and associations. Give a full idea of your responsibilities with the family members, friends and associations. Give a full idea of your responsibilities in life and what you feel about them.
Education qualification? If not studied, why or were you interested in something else.
Occupation? Job satisfaction? What you do for work, (ideally, what would you like to do).
Financial responsibilities and strain (present as well as past), Difficulties experienced in the place of work, Family are/Society give a full account.
MENTAL AND EMOTIONAL SYMPTOMS
How would you describe yourself? (Amiable, a loner, quite social, a tendency to be very picky about things like cleanliness and keeping appointments etc.)
How do you react to stress and tension? (Tend to be verbally expressive, tend to keep things to yourself and brood about them, etc.)
What is the greatest sadness in your life now? How did u react to it?
What are the greatest joys in your life now?
Do you ever feel jealous? If so, in what circumstances
Do you cry easily? If so, on what occasions, at music, at reproaches (self blames)? At what time of day, or any other incident? (You could give an incident here that springs to your mind)
How do you cope with your worries, how do you react? What would cause you to worry?
When you are upset, do you tend to tell a lot of people or keep it to yourself?
What effect does consolation have on you? (Do you like it or not? are you indifferent maybe?).
Have you ever felt despair, if so when?
Does having to wait for anything or standing in a queue bother you?
Would you ever feel frightened or anxious at anything or in any situations? (Darkness, being alone, altitude, flying, elevators, etc)
How do you feel in a room full of people, at church, at mosque, at a lecture?
Do you get angry ever? If so what do you do if you get angry? What makes you angry? Does your face colour red or pale when you are angry? How do you feel after getting angry?
How are you affected following chagrin, grief, disappointed love, vexation (annoyed), mortification (humiliated), indignation (anger from injustice), bad news, fright?
Would you say you are over-conscientious or over careful about anything or even small things? (Some of us don't care about details and some of us care a great deal).
How is your memory? (What would you forget? Give details please).
Your understanding? (How do you comprehend and process information, either spoken or written)?
Your concentration? (E.g. does your mind wander)?
Any tendency to make mistakes? (In writing or speaking or any other?)
Your will? (Is it strong etc.)? Can you handle any responsibilities given to you alone any
How good are you in taking decisions? (Can you take decisions yourselves on spot or do you think a lot and )
then decide or is it that you have to take someone's advice for decision or till end you are confused) Do you stand firm in your decisions?
In what situations do you feel the depressed, sad, and pessimistic? In time of depression, how do you look at death?
How do other people view you?
What would you like to change most about yourself?
FEMALE PATIENTS a) Age at onset of periods?
b) Periods? Regular/Irregular; interval between periods. Duration, abundance, color, time of day when flow is greatest; any odor or clots
c) Physical symptoms preceding the onset of periods (e.g. heaviness/pain in the breasts, changes in moods, changes in appetite, changes in bowel habit, backache, pain in the legs, headaches, dreams, any mood changes, etc.)?
d) Are you using any contraceptive pills?
e) Any discharge before/during/after periods?
f) Number of children and whether the deliveries were normal?
g) Any post-delivery problems?
h) Were the children breastfed or not? Any problems during the breastfeeding phase?
i) Any abortions/miscarriages? Any complications after abortions?
j) Age of onset of menopause? Did the periods cease gradually or abruptly
k) Have you had any operations done in the pelvic area? If yes, details
l) How do you (did you) feel before, during and after menses?
1) Medical Report and opinion on your state of health from your physician.
2) Copies of Reports of Investigations done.
3) X-ray plates, Electrocardiograms, etc.
Attach Resume :