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Case Taking Form
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Case Taking Form
Fields marked with an * are required. Please provide detailed and correct information.
Name
*
Age
Sex
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Male
Female
Marital status
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Married
Single
Occupation
Address
Email address
*
Chief Complaints
If the case is already diagnosed then diagnosis of the case
If investigations done, reports of investigations
Under any medication, if yes specify
Present History
Whether patient is suffering from any diseases like Arthritis, Blood Pressure, Diabetes, HIV, Tuberculosis Or cancer specify since when
Past History
Any diseases which occurred in the past Tuberculosis, Hepatitis, Typhoid etc. any others specify when
If Patient has undergone any surgical intervention for what and when
Family History
Family history of any diseases (for Father, Mother, Brother, Sister) Blood pressure, Diabetes Mellitus, Hepatitis, Tuberculosis, Cancer, HIV Infection etc. any others specify Arthritis
If married � about children. Any diseases specify
Patient's Nature
Appetite
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Increased
Decreased
Normal
Craving for any food or drinks specify
Aversion for any food items
Thirst
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Increased
Decreased
Normal
Perspiration
Type
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Generally Increased
Generally Decreased
Any parts specify
Urine
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Normal
Increased
Decreased
Offensive Smell
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Yes
No
Pain
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Yes
No
If yes type of pain specify, before/after/during
Bowel Motion
Type
Select
Normal
Loose Stools
Constipated
No. of times /days
Thermal
Climate � which patient prefers
Takes bath in
Select
Hot Water
Cold Water
Addictions
Tobacco
Select
Yes
No
If Yes, Quantity
Alcohol
Select
Yes
No
If Yes, Quantity
Drug
Yes
No
If Yes, Quantity
For Females
Menstrual flow for how many days
First Menstrual Period
Last Menstrual Period
Attained Menopause
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Yes
No
Complaint Associated with Menses
Before
During
After
Leucorrhoea
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Yes
No
Sexual History
About sexual life. Any problems specify
About fertility. if any problems
Mental Features of the patient
Any other problems, specify
Test Report
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