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personal Details  
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About patient's medical condition
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MEDICAL CONDITION

Chief Complaints
(with duration)


History of Present Illness

 (Elaboration of chief complaints, with mention of general symptoms of disease, viz. history of loss of appetite, weight loss, history of bladder, or bowel abnormalities)


Treatment History

 (With elaboration of details of previous treatment undertaken)


Family History

 (Any significant family history of disease, related to current chief complaints)


History of Present Illness

 (Elaboration of chief complaints, with mention of general symptoms of disease, viz. history of loss of appetite, weight loss, history of bladder, or bowel abnormalities)
 
Past History
Please select Yes or No wherever applicable; if Yes please provide more information in the adjacent text area, e.g.,
if suffering from hypertension, select Yes, and enter recently recorded blood pressure reading(e.g. 120/80 mm Hg)
Arthritides Yes No
Asthma Yes No
Diabetes Mellitus Yes No
Dyspepsia Yes No
Heart Disease Yes No
Hypertension Yes No
Tuberculosis Yes No
Exposure to STD
(sexually transmitted disease)		 Yes No
Jaundice Yes No
History of Trauma or Injury Yes No
History of Surgery Yes No
History of Gynaecological disease
(for women)		 Yes No
History of any other disease(s)
not mentioned above:
Personal History
Non vegetarian? Yes No
Do you take any Medicines? Yes No
Drug(s) Details :
Do you have a history of smoking? Yes No
Duration (in years)
Number of cigarette(s)
or pack(s) per day
Do you have a history of consuming alcohol? Yes No
Alcohol Type
Duration (in years)
Alcohol intake per day
Do you have history of chewing tobaco? Yes No
Duration (in years)
Do you have a history of allergy(s)? Yes No
Allergy(s) details :
Any other habits?
Attach soft copy(s) of other report(s) (if any)
Report 1   Report 2  
Report 3   Report 4  
Report 5   Report 6  
 
   
 


 
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