History of Presenting Complaints: →
Please write the history of each of the above presenting complaints.
When the complaint started?
How the complaint started?
What is the time of aggravation (increased suffering time)?
Where is the complaint exactly?
Any sensations, ex:Burning, Itching, Stinging, Stitching etc? Please explain.
Past History: →
History of past complaints i,e the diseases from which you had suffered in the past. Explain in detail also the treatment you have taken for that complaint.
Family History: →
Explain the health status of your family members like Children, mother, father, brothers, sisters, maternal-paternal relations, wife/husband ect.If they are suffering/suffered from any disease frequently or any long standing disease explain?
Habits & Addictions: →
Please explain if you have any habits like cigarette(how many/day),alcohol (how much),or any other?
General Status: →
Explain your general status like any special or abnormal characters regarding your hair,skin,eyes,lips(color),teeth,tongue,nails etc.
Physical Generals: →
Explain about your thirst,appetite,sweat,stool,urine,sleep,tolerance to cold and hot weather etc?. Also use the below fields.
Desires & Aversions: →
Explain the things which you like much to eat, dislike, not tolerable or gives trouble if taken.
Please write your mentality like angriness, weeping tendency, fearfulness, anxiety etc. Please take the help of your life partner or close friend to fill this field.
Please write details of investigations of your disease, you had undergone. in the form of lab reports if you have any please write those details here OR send as attachment.
Signature of the Patient.