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Personal Details
Name
Age
E-mail Address
Phone Number
Sex Male Female
Marital Status
Religion
Height
Weight
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Present complaint
   
Problem History
History Write about any other disorders you had in past like jaundice typhoid etc..also mention if you have undergone any surgeries before.
Associated complaints Mention about any associated problems for which you are already on medication like diabetes hypertension etc.also mention all details about any associated small problems too.
   
Treatment History
If any kind of previous treatment
taken for the present complaint.
Investigations
 Scan and attach the laboratory reports and investigations done related to the previous complaints
   
Personal Details
Appetite Normal More Reduced
Bowel Normal Redish Blackish Greenish Sticky Loose Watery Other
Micturation Normal More More at Night Less Yellowish Burning Redish Sticky Other
   
Diet Regime
Breakfast Time
Lunch Time
Dinner Time
   
Exercise
Do you Exercise? Yes No
 
Nature of Job/ Work Sitting for long /standing for long/etc.
Time of Sleep
Wake up time
Do you get sound sleep?
Do you get Dreams?
   
Habits
Habits Smoking Drinking Tobacco Other
Do you drink water after getting up in the morning? Yes No
Drinking water before sleep? Yes No
drinking milk before sleep? Yes No
Mention If any other