| Name |
: |
|
|
| Street |
: |
|
| City |
: |
|
| State |
: |
|
| Country |
: |
|
| Zip/Postal
Code |
: |
|
| Telephone |
: |
|
| Fax |
: |
|
| E-mail |
: |
|
| Age |
: |
|
| Sex |
: |
|
| Weight |
: |
|
| Structure |
: |
|
| Occupation & Nature
of Work |
: |
|
| Present Complaints with
full history |
: |
|
Past History
(Previous
problems & surgery) |
: |
|
|
Any chronic illness like
Diabetes/Hyper tension/TB/Heart Diseases &
medicines taken now |
: |
|
| Have the patient's
relatives had the same problem |
: |
|
| Any cause known to you
for the disease |
: |
|
|
State of digestion,
motion, micturition, appetite and
sleep |
: |
|
| Marital
Status |
: |
|
| Treatment done so
far |
: |
|
Recent investigation
reports
(blood, urine, motion,
x-ray, CT scan
etc) |
: |
|
| Blood
pressure |
: |
|
