CONSULTATION
* Indicates Required Fields
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Health Concern(s):
In the order of appearance
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History of present condition(s):
Explain in detail how and when the condition(s) started, progressed and the present state.
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Personal History:
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Past History:
Any diseases which occurred in the past like tuberculosis, hepatitis, typhoid, arthritis, blood pressure, diabetes, HIV, cancer etc., may be described in detail in sequential order. Also specify any other diseases from childhood down to the present, chronologically with its nature, duration, severity, type of treatment undergone etc. in as much detail as possible.
Have you undergone any surgical procedures? If so, for what and when?
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Prescription Drugs:
List the medication(s) and the dose(s) you are taking and the reason(s) as to why.
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Supplement / Vitamins and Non prescription drugs:
List all the supplements, Vitamins and Non prescription drugs you are taking with the amounts.
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Family History:
Please list any relevant diseases in your immediate family. Examples: Blood pressure, Diabetes, Hepatitis, Tuberculosis, Cancer, HIV Infection, Tumors, Arthritis, Skin diseases etc.
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Personal History:
Specify life situation
(Mile stones and other developmental details in children)
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| Do you consume / use any of the following: |
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| Tobacco |
Yes |
No |
if yes quantity:
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| Alcohol |
Yes |
No |
if yes quantity:
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| Drugs |
Yes |
No |
if yes specify:
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| Patient as a person: |
| Appetite: |
Increased |
Decreased |
Normal |
| Thirst: |
Increased |
Decreased |
Normal |
| What kind(s) of food do you crave? Examples: Sweets / Salty / Sour / Spicy |
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| What food(s) do you have an aversion to? Any food or environmental allergies? |
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| Perspiration: |
Generally Increased |
Generally Decreased |
Normal |
| Any parts specify |
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| Offensive / Sour smell / Non Offensive |
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| Urine: |
Increased |
Decreased |
Normal |
| Pain / Smell |
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| Type of pain / type of smell |
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| Bowel Movements: |
Normal
Constipation
Loose stools
Hard stools |
| Number of times per day |
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| For Females: Menstrual history |
| Menstrual flow for how many days |
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| First Menstrual Period |
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| Last Menstrual Period |
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| Attained Menopause: |
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Yes |
No |
| Complaint associated with periods: |
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Sexual History:
Please specify any problems or concerns.
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Sleep:
Nature, duration, position, dreams, snoring etc
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Mind:
Patient's reactions towards society, stress, family and friends.
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Any other details:
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