Address:

Phone Number:

Email Address:

Date of Birth:

Sex: Male Female

Height: Weight:

Marital status: single married divorced widowed with a steady partner

Number of children:

Religion:

Veg/Non Veg:

Addictions: Smoking /alcohol /tobacco/Tea /Coffee/any other specify daily consumptions

Chief Complaint:
Describe fully what bothers you most in detail .Each complaint should be described fully
a. Right from its onset to its subsequent development, treatment taken so far and response to the treatment
b. Areas affected: location sensation, direction of spread, sequence of events
c. Conditions that bring on the trouble/aggravate it paying attention to physical as well as emotional factors
d. Factors that increase the trouble/afford relief
e. Any other ailments experienced at the same time as the chief complaint for example perspiration/nausea/gases/sleeplessness/headache/pain.

Other Complaints:
Describe any other problems other than the chief complaint that you are experiencing now or have experienced in the past.

About yourself:
Give a physical description of self followed by perception of yourself with regards to your Emotional nature,
Intellectual attainments and aspirations,Indicate to what extent you have been able to realize them.
Give a picture of your life, relationships and friendships.
Do you suffer from anticipatory anxiety? Are you careful/careless, optimistic/pessimistic, hurried /slow, mild/irritable?
Anything else that you can think of please do make a note of it.

Educational qualifications, current occupation with full description of responsibilities and job satisfaction.
Current family setup with in detail pertaining to all family members, their ages, what they are doing, your relationship,
responsibilities towards them, including those that have died stating their age/cause of death.
Financial responsibilities /strains past present.
Any issues /difficulties experienced at work/family setup/social setup. Your daily routine from time you wake up to
the time you retire at night including your dietary consumptions during the day.

Reaction to surroundings:
* Food desires/aversions-foods that do not suit
* Apetite
* Thirst
* Perspiration
* General environment: weather/temperature
* Sleep and Dreams
* Sex (including menstrual and obstetric history in women)

Previous Illnesses:
Any illnesses/surgeries/ailments you have had in the past

Current Medications and Allergies if any:
Please list all medications that you are taking specifying their dosages

Skin complaints:
Warts /corns/keloids/pimples/itching/eczema anywhere on the body

Family History:
Diabetes/Hypertension/Heart disease/Asthma /Epilepsy/other

Enclosures:
Copies of any reports: bloodwork/Xray/MRI/CTscan/ECG /other

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FOR PEDIATRICS PATIENTS ONLY

Childhood complaints:
* Nocturnal Enuresis (bedwetting)
* Pica (eating mud/plaster/chalk/other)
* Thumb sucking/attachment to a particular toy/blanket
* Drooling saliva
* Appetite (increased/decreased)
* Urine (offensive smell/burning)
* Stool (loose stools/constipation hard stools)
* Perspiration (excessive/smell/stains)
* Feet/socks smell?

Child’s Nature/Behavior:
(Preferably both parents should write their own description of the child)
In your own words describe your child as best as you can his weaknesses
his strengths, his fears, his likes /dislikes, anything that you can think of
* Sensitivity to pain/noise, Better /worse consolation, timid/brave
* Behavior towards animals, drops/breaks things/destructive
* Any fears dark/ghosts/separation anxiety/thunder/other
* Dependant/clingy/independent
* Reaction when denied what he/she is asking for
* Overactive, Craves attention, Restless, Angry, Mild

Milestones:
Walking, talking, crawling
Social interactions
(Plays alone/with others, leader/follower, talkative/quiet,
Plays with younger/older children/peers,
Competitive/aggressive/shy, Reaction to strangers)

Mother’s state during pregnancy:
Description of pregnancy/labour/childbirth
Any complications/complaints (physical/emotional)