Name

:

Age

:

Sex

:

Male Female

Marital Status

:

Single Married Divorced

Occupation

:

Address

:

E-mail

:

Chief complaints

In the order of appearance with duration of each complaints

:

History of present illness

Explain in detail how the complaint started, progressed and the present state. Each complaint may be explained in the same way. 

:

Past history

Any diseases which occurred in the past like tuberculosis, hepatitis, typhoid, arthritis, blood pressure, diabetes, HIV, cancer etc., may be described in detail in sequential order. Also specify any other diseases from childhood down to the present, chronologically with its nature, duration, severity, type of treatment undergone etc. in detail.

If Patient has undergone any surgical intervention for what and when

:

Family History

Detailed description of Father, Mother, Brothers, Sisters, Uncles, Aunts, Grand parents, Children with their age and any relevant diseases (Blood pressure, Diabetes, Hepatitis, Tuberculosis, Cancer, HIV Infection, Tumors, Arthritis, Skin diseases etc.)  

:

Personal History

Specify life situation

(Mile stones and other developmental details in children)

:

Addictions

Tobacco

:

Yes No

if yes quantity:

Alcohol

:

Yes No

if yes quantity:

Drugs

:

Yes No

Specify           :

Patient as a person

Appetite

:

Increased Decreased Normal

Thirst

:

Increased Decreased Normal

Craving of any food items specify as salt,sweets,sour,chillies,cold/hot etc

:

Aversion/ Allergy for any food items specify

:

Perspiration

:

Generally Increased Generally Decreased Normal

Any parts specify

:

Offensive / Sour smell / Non Offensive

:

Urine

:

Increased Decreased Normal

Pain / Smell

:

Type of pain      /type of smell   

:

Motion

:

Normal Constipation Loose stools Hard stools

No. of times /days

:

Thermal :

Climate which patient prefers

:

Takes bath in

:

Hot Water Cold Water

Body feels warm / cold

:

For Females: Menstrual history

Menstrual flow for how many days

:

First Menstrual Period

:

Last Menstrual Period

:

Attained Menopause

:

Yes No

Complaint associated with Menses

:

Before

:

After

Leucorrhoea, its nature,color,constitency,before or after menses,duration etc.

:

            Yes No

Obstetric, Gynecological (Menopausal) history in detail

:

Sexual History

About sexual life. Any problems specify

:

Sleep : Nature, duration, position, dreams, snoring etc

:

Mind

Patients reaction towards the society, family and friends. Whether irritable, anxious, tensed, suspicious, likes company of  friends, brooding,

 any suicidal thoughts etc.

Any other details may be added

: