ONLINE CASE HISTORY FORM
Please provide the following contact information:
should be useful to you in describing your complaints in detail. Your
response will help me decide the proper line of treatment for you. In
describing your complaints please be as complete as possible. We
require the following details of each of your symptoms: NOTE
charges are applicable.
I want to Consult for
Loss of Memory
Loss of weight
CAUSE: The likely
cause (s) of your present symptom.
exact site, side and where the symptom spreads.
The type of sensation or pain, in your own words, however simple or funny
it may seem.
All factors that tend to either increase or decrease the intensity of your
Quantity, Consistency (thick, thin etc.), Color. Does it irritate or make
the parts raw and sore? Is it blood stained?
PART 1: History of
your present illness. Please describe each of your symptoms (as given
above) in chronological order.
Past history of illness. Any medical, surgical, gynecological or mental
illness that you have had from childhood to date.
Family history of illness- in parents, siblings, children, grand
parents, uncles, aunts, etc.
About yourself. Please describe the following things about yourself:
appetite, food-cravings & aversions, thirst, bowel activity, urinary
symptoms, sweat (where, how much, smell, stains, etc.), any abnormalities
or peculiar problems in the skin, hair, mouth, teeth, gums, ears, eyes,
nose, nails. Your reaction to heat and cold. Any habits or addictions? Are
you thin, stocky or obese? Is your tongue coated?
Menstrual function. Are your cycles regular? How long do they last? Is the
bleeding profuse, moderate or scanty? any clots, odor, stains? What is the
color of the menstrual discharge? Any symptoms associated before, during
or after the menses? Do you ever get a white discharge? Can you describe
it? How many pregnancies? Any problems during labor? Any miscarriages or
Sexual problems. Any particular feelings or symptoms appear before, during
or after sexual intercourse? Increased or decreased desire for sex? Any
other sexual disturbance?
Sleep & Dreams. Is anything unusual about you in sleep? Is it disturbed?
Do you suffer from insomnia? Can you tolerate lack of sleep? What type of
dreams do you get? Any recurrent dreams?
Mental state. Describe freely and frankly your anxieties, fears, worries
etc. Do you often become depressed? When? Do you ever become suicidal? Do
you brood a lot or harbor pent up feelings? Are you irritable? Impatient
or hurried? Jealous or revengeful? Do you weep easily? When? How do you
react to consolation and sympathy? Are you shy, timid, reserved,
introvert, extrovert, dominating, mild and yielding? What is the greatest
grief or joy that you have experienced?
Give a picture of your situation in life and your relationship with each
of your family members, friends and associates.
Please answer the relevant questions and try to be as
accurate and frank in your answers to the above questions.
If you have any problem in filling or sending Case
Record Form then Copy this form and send by email directly to us at
or Call at +91-2452-222261 between 9 to 2 am and 5 to 9 pm at Clinic.
Please contact me as soon as possible regarding this matter.
© Copyright With Dr. Pawan S.