CASE TAKING PROFORMA


Personal Information
Name :*
Age :*
Sex :*
Marital status :*
Address
State :*
Country :*
Pin Code :*
Tele No. :*
Email :*
Job Describtion: :*
Presenting Complaints :(Complaints for which you are coming to the doctor):

1.*     

Symptom Onset (sudden/ gradual). Duration of complaint (since how long you are suffering). Aggravation (with reference to weather/ time of day/ body posture/ movement etc) Amelioration (with reference to weather/ time of day/ body posture/ movement etc) Any associated complaint

2.         

Symptom Onset (sudden/ gradual). Duration of complaint (since how long you are suffering). Aggravation (with reference to weather/ time of day/ body posture/ movement etc) Amelioration (with reference to weather/ time of day/ body posture/ movement etc) Any associated complaint

3.         

Symptom Onset (sudden/ gradual). Duration of complaint (since how long you are suffering). Aggravation (with reference to weather/ time of day/ body posture/ movement etc) Amelioration (with reference to weather/ time of day/ body posture/ movement etc) Any associated complaint

4.         

Symptom Onset (sudden/ gradual). Duration of complaint (since how long you are suffering). Aggravation (with reference to weather/ time of day/ body posture/ movement etc) Amelioration (with reference to weather/ time of day/ body posture/ movement etc) Any associated complaint
Has the diagnosis been made (mention the diagnosis, if any):
Treatment History
(Name of medicines taken previously for the current problem):


Past History: (Any major illness suffered by you since your childhood):
Name of Disease Age at which suffered Duration of illness Treatment Taken

Family History:
Relations Alive/Dead Age Diseases Suffered Cause of Death Any other particulars
Paternal Grand Father
Paternal grand Mother
Maternal Grand Father
Maternal Grand Mother
Father
Mother
Brother 1
             2
Sister 1
          2

PERSONAL DETAILS
How is your Appetite: * Habits - Do you take drugs, tea,cofee,opium,alcohal, cigrettes etc.?If so how much in quantity often.*
Response to weather:what weather preferences you have Summer/ winters. How you respond to the weather changes summer/winter/spring/autumn/rainy weather.* Eating habits (do you prefer to eat Sweets/ salty/ Sour/ Spicy.) *
Thirst: How much and how often you like to drink water and its relation with weather changes?* Sleep.*
Sweat. (on any specific parts/ odor/profuse or scanty) * Bowel/Stool habits*
Urination.: frequency/ odor/ character * Any other detail(optional):

MIND
Are you Anxious? About which matters? Are you fearful of anything such as animals,
people, being alone, darkness, disease, high places?*
How punctual are you for any appointment?* How Sensitive or emotional are you?*
How would you grade your self confidence?* Do you weep easily?*
What makes you weep?* How do you feel if someone offers sympathy and consolation?*
Do you like Company? Or do you like to remain alone?* What are the greatest griefs that you have gone through in your life?*
What are the greatest joys that you have had in life?*



ADDITIONAL QUESTIONS FOR FEMALE PATIENTS
Age at onset of periods?
Periods? (Regular/Irregular) RegularIrregular
Physical symptoms preceding the onset of periods (eg: heaviness/pain in the breasts, changes in moods, changes in appetite, changes in bowel habit, backache, pain in the legs, headaches, dreams etc.)?
Duration and interval between periods (eg: bleeding last for 3-5 days and the interval between periods is 27 days)?
Are you using any contraceptive pills? NoYes
Any discharge before/during/after periods? BeforeDuringAfter
Number of children and whether the deliveries were normal? Any post-delivery problems? Were the children breastfed or not? Any problems during the breastfeeding phase? Any abortions? Any complications after abortions? (Give detail of each section separately)
Age of onset of menopause?
Did the periods cease gradually or abruptly? GraduallyAbruptly
Have you had any operations done in the pelvic area? NoYes

Charges:

For Patients in countries other than India, charges shall be as follows :

First Consultation: US $-250 + courier charges------------
Follow up: US $ 100---------

The Charges for Indian patients shall be as follows:

First time Consultation: Rs. 1500/----------------------
Follow up: Rs. –750 /Once every 15 days)

Medicinal charges-inclusive(excluding courier charges). (The medicines are of German make, and shall be sent across to any city in India within 3 working days of the case history first being received by us.)
The Payment has to be made in advance.


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