Case Record Form

We want to know you and your problems in detail. So In order to help you with the best medicine it is necessary for us to know about your problems and understand you as a person in as much as depth possible. Feel free to tell us everything minutely in detail and trust us that we will keep it confidential.

Name

Age

Date of Birth

Sex

Height

Weight

e-mail

Dr. Name

Dr. Address

Home

Postal Code

Religion

Occupation

Marital Status

Contact Number

May I Contact

Cell#

Emergency Contact Name

Emergency Number

Have you had massage/physio/acu/naturo/chiropody treatment before

Previous major Illnesses (Operations, Presence of Internal Pins)

Motor Vechicle accidents (Please give dates)

Current medications

Other medical conditions (e.g Hemohilia, Diabetes, Cancer, Epilepsy)

Family history (major illnesses, operations, Arthritis)

Referred by

Present complaint and its details

When & how it started

What makes it worse?

What makes it better?

Describe any other associated problems along with the main complaint.

Which weather affects you or worsens your problem?

At what time, season, or weather are your problems maximum/minimum?

What is the most comfortable position for you (including during sleep)?

Any unusual things that happen to you (like standing, teeth-grinding, or walking in sleep)?

What do you like to eat or drink?

What do you dislike in food or drink?

What makes you happy?

Any food items that give you key problems?

Any habits (like smoking, sleeping late, alcohol, tea/coffee, etc.)?

How many glasses of water do you drink daily, and at what time?

Any constipation or difficulty in passing stool?

Any sexual or personal problem you face

Male: Indulgence in past & present: Habit of masturbation, if any: Erection problem, if any

Any other sexual trouble: Inclination or attraction to same sex

Only for female

Any problem related to periods

At what age your menstruation cycle started and associated problem during that time

Pain or discomfort in body

Average cycle is of how many days

No. of days of bleeding

Bleeding character (flow more/less-color clots etc.)

Any other changes before during & after Menses

Last Menstrual period was on

No. of pregnancies

No. of Childbirths

Method of deliveries

No of Abortions if any

Problems faced during the pregnancies, if any

Changes before and after deliveries & abortions; if any

Discomfort during or after making a sexual relation

Increased desire or dislike to sex

Any discharge per vagina, color, and stain, easy to wash or not

Family history-any major illness

Maternal Family

Paternal Family

Past medical history

Major diseases suffered- (Diabetes Anemia Cancer T.B. Rheumatism Epilepsy, Asthma, Heart Trouble, Kidney Trouble, Liver, Hypertension, Any Accident or Surgery Etc)

Any long illness, if ever had & treatment taken

Any allergic reaction to any food medicine or anything

Any Animal bite or anything like this & treatment taken

Past stressful events

What you love to do

What you hate

What makes you sad

What kind of life you want

Is there anything else you would like to communicate?