Consultation
Name
Sex
Age
Marital Status
Occupation
Date
Address
Phone
Reference [ who referred]
Chief Complaint
Started since when - chronology
How better or worse
Aetiology [Possible conditions or situations that may have led to present ailment, eg. – it all started after getting wet, after death of a close person, etc.]
SPECIAL STATUS
Any concurrent problem for which already taking medicine [related or not related to current problem – like BP / Sugar/ Heart/ Skin etc]
Appetite
Stool
[Formation/frequency and conditions associated with it]
Urine
[frequency and conditions associated with it]
Thirst
[frequency, quantity and conditions associated with it]
Menses
[Regular = 28 days/ Late/ Early/ Irregular = no fix interval/ Intermittent =in between periods/ Duration/Difficulties associated with it]
Last Menses Date
Leucorrhoea
[Yes or No/ Thick or Thin/ Conditions associated with it]
Sex
[Inclination and difficulties- if any]
Reproductive history [ number of children/ abortions/miscarriages etc, any difficulty in pregnancies]
Sleep
Dreams with feeling at that time
Perspiration
[scanty/ profuse or conditions that cause this change]
Thermals
[Sensitive to heat or cold]
On Examination
To be recorded by physician
Past History of illnesses
Birth [ complaints to mother during pregnancy, own complaints soon after delivery, problems during birth – early/late etc, delivery normal or CS – reason for CS]
Family makeup [ number and sequence of siblings, general socioeconomic status of family]
Mother
Brothers
Sisters
Grand Father
Grand Mother
Maternal Grand Father
Maternal Grand Mother
Family in general - paternal
Family in general - maternal
Uncles and Aunts [Father’s brothers and sisters – not their spouses]
Uncles and Aunts [Mother’s brothers and sisters – not their spouses]
Generalities
To be recorded by physician
Mental – Nature
[Shy/Aggressive/Mild/helpful/Mischievous, etc and conditions associated with such behavior]
Habits
[Alcohol/Smoking/gambling or other habits]
Liking
[foods, colours and other things of strong liking]
Disliking
[foods, colours and other things]
Fears if any
Irritability and Anger
[conditions that precipitate anger etc]
Present Stresses
DIAGNOSIS [ to be recorded by physician]
Records (Attach copies/scans of medical records/test-reports / scans / photographs etc – if any)
