Case Taking Form

ESSENTIAL INFORMATIONS

NAME———————————–AGE——-SEX——–

Address with telephone number

Occupaton/income/religion

Chief complaints with the following

How it starts?    gradually or suddenly?

Where exactly the complaint is?

What is the exact sensation? Eg, pain,numbness, twiching, burning etc

What are the factors that worsen or  improve the complaints? Eg, rest, movement, hot, cold,pressure,day,night,morning,noon,evening etc

Describe the associative complaint(s), if any

Past History

Past history of similar diseases or any other diseases with treatment history.

Family History

Family history of similar disease or any other diseases like diabetes, hypertension, thyroid problems, cancer etc

Describe the following

Appetite: increased or decreased, regular or irregular diet habits.

Thirst: increased or decreased, total intake per day, hot or cold, quantity at a time, with or without dryness of mouth.

Bowel habits: constipation, diarrhoea, bleeding, pain, burning.

Urine: frequency, quantity, colour, burning,specific odour.

Sweat: increased or decreased, single parts or whole body

Sleep: delayed, middle awakeness,early morning awakeness, disturbed, restless, unrefreshing, drowsy during the day.

Dreams: fearfull, repeated, disturbing, specific.

Menses: age at first menses, regular or irregular, early or delayed, date of last menses, nature of blood, profuse or scanty, painful or painless, history of white discharege if present  

Likes and dislikes in food, in general.

Comfortable climate and reaction to temperature in general.

Level of irritability, anger, shyness, restlessness, suicidal tendency, depression, grief,emotion,disappointments etc

 

Laboratary Invetigation reports if any 

 

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