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Name :
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date of Birth |
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Address
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Sex |
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Mobile No. : |
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Email Id |
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Occupation :
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Martial status |
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1. Chief Complaint :Main problem
with duration, origin& relation with place, diet, food, occupation with detailed symptoms. |
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2. History of present complaints :
All
details about the history of the present
complaint. Onset of symptoms and the
factors relieving the symptoms (Rest,
exercise, season, place, medication ) |
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3. History of past
illness
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All details about the
previous illnesses you have suffered from (infections,
injuries, systemic diseases) along with the age
of onset & duration). |
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4.Treatment history :
Tell the diagnosis if already known. Describe the
treatments you underwent and medicaments /
therapies you are undergoing now. You should
describe the order of use of the medicines and
the response to the treatment. |
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5. Gynecological History :
Please cover the following
points in your information.
*Age of menarche.
*Regularity of cycle
*Flow of cycle (Normal, scanty or excess).
Are you taking any contraceptive pills.
*Age of menopause
*Discomforts with menses( pain, vomiting, giddiness).
*Any abnormal discharge like leucorrhoea.
*Details of pregnancies & type of delivery. |
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6.
Personal history :
a. Atmosphere at the
job, family or the society.
Does your disease or symptoms have any relation
to the above? |
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b. Bowel habits.
Time of the day
when you usually go for bowel movements.
Frequency
Colour of stool
Consistency
Whether foul smelling
Regular or irregular ?
associated with pain, burning sensation or
itching ? any protrusion ?, blood spots
or bleeding? |
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c.
Urine habits.
How many times you go for urination( in day & in
night). Associated with burning or not?
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d.Allergy
Towards
particular food, medicines, dust, climate or
others |
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e.Dietry
habits
Vegetarian/Eggetarian or non-vegetarian)
Appetite (Good/excessive or low)
Addiction (Tea/Alcohol/smoking/drugs)
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f.
Sleep habits
Good & Sound/Irregular/Disturbed
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g. Working habits
Sedentary/Touring/manual work |
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h. Influence of climate or environment.
Describe briefly the type of climate and
environment in which you live ? Is there any
relationship to the climatic condition? Do these
symptoms increase or decrease in a particular
climate or environment ? |
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7. Any other information that
you feel might help in making a proper
diagnosis.
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8. Reports of any other clinical
investigations. |
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