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Please read the questions and examples (if present) carefully before filling. Feel free and be frank enough to give us correct and detailed information on each point. All the information filled in here by you play a vital role in the diagnosis and treatment.
All the information furnished here shall be kept confidential. |
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| Please give a detailed description of your present complaints. |
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| Past History |
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Please narrate all the previous illness you have suffered. It includes poisoning, drug abuse, accident, trauma etc., and the age at which it happened
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| Click to view the Example |
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| Family History |
| Fill in your family details here. |
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| Details of Siblings |
| Fill in the details of your brothers and sisters (if any) |
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| Personal History |
| Fill in the answers to questions regarding your personal history. |
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| 1. Chewing |
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| 2. Smoking |
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| 3. Laxatives/purgatives |
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| 4. Sleeping pills |
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| 5. Any other |
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| PRESENT COMPLAINTS |
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Give correct and complete details of the present illness with the date of onset and course. Each symptom should be complete in location, sensation and modalities (ie, which all factors/things makes the complaints worse and which all factors/things make the complaints better)
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| Click here to view the example |
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| Appetite and Thirst |
| Any particular desires and aversions – check the appropriate columns in the table below. |
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| Other Information and Habits |
| A general questionnaire on your general habits and body responses. Kindly give sufficient details wherever necessary. |
| Bowel habits: |
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Any problem regarding your stools? |
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Any problem about bowel movements? |
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Is there any urgency? |
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| Bladder habits: |
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Any problem with urination? |
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Any involuntary urination? When does that happen? |
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| Sweat/Perspiration - Fever-Chill: |
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What is the smell like? |
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Do you perspire on the palms or soles? |
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| Chest/Heart: |
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Is there any difficulty in chest, heart, breathing? |
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| Sex |
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Any excessive indulgence in sex in past and present? |
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Any effect on your health? |
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Any habit like (masturbation etc.) in past as well as present? How often? |
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Have /had any Venereal disease? |
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Do you have increased desire or decreased desire for sex? |
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| Masculine |
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Any erective malfunction? |
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Any other trouble in sex?(Give in details) |
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Any other complaints in any other organs?(Give in details) |
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What is your thermal reaction, i.e. Which climate do you like/dislike? |
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In which climate do you feel comfort/discomfort? |
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Does any climate affect your disease? |
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| Feminine |
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Menses; is /was it regular/irregular? |
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At what age did it start? |
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Is there any change in quantity, color, smell? |
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Since how long? |
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Do you suffer before, during or after menses? If so, describe: |
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Is there any white discharge? |
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If so, mention the nature, color, consistency and smell of discharge. |
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When and under what circumstances is it more or less? |
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Has the discharge any relation to menses? |
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Any itching, excoriation etc. due to discharge? |
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When was your menopause? |
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Any other complaints in any other organs?(Give in details) |
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What is your thermal reaction, i.e. Which climate do you like/dislike? |
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In which climate do you feel comfort/discomfort? |
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Does any climate affect your disease? |
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| Sleep and dreams |
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How is your sleep? |
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Any particular position do you prefer in sleep? |
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Any particular dreams (Give in detail)? |
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During sleep do you: |
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Snore? Grind teeth?
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Dribble saliva? Sweat?
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Keep eyes or mouth open?
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Walk? Talk? Moan? Weep?
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Become restless? Wake up with a jerk?
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Give full and correct details about your mind i.e. memory, feelings, sentiments, grief, activity, irritability, anger, delusions, anxieties, fears, phobias, enmity, depression, brooding habit, tendencies, etc; etc.
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Wishing you a speedy cure |
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