General PatientsDr. Urmika2020-05-05T10:23:58+00:00 General PatientsHome > General Patients Form for General Patients First Name* Middle Name * Last Name * Street Address * City * State * Pin code * Country * Phone * Email * Date of Birth * Gender MaleFemale Occupation Weight Alcohol UsageTobacco Usage Veg / Non-Veg VegNon-Veg Chief Complain in Brief General Information How is your appetite? Are you carving about particular kind of food (eg. Sweet, Sour, Salty, Spicy etc.)Are you sensitive or allergic to any kind of food How is your liquid intake (eg. Thirsty, Moderate, etc.) What kind of weather are you most comfortable in (eg. Summer, Humid weather, Winter, etc.) Are you particularly uncomfortable in any weather or climate? What about your perspiration? (eg. Profuse, Moderate, Scanty, etc.) In general do you like being out in the open air or do you feel more comfortable in closed room? Elimination How is your bowel habit (eg. Regular, Constipated, Diarrhea, etc.) Is if modified by anxiety or diet? (eg. Spicy food causes diarrhea) Is there any complain in urination? (burning / dribbling) Sleep How is the quality of your sleep? (Sound / disturbed / feel tired most morning etc.) Do you dream at all? if you, do you remember them? what type of dream? (eg. Daily event, falling into space, etc) Nature How would you describe your self? (eg. Reserved, talkative, quiet, social, professional, etc.) How is your reaction in stress and tension? (eg. Verbally expressive, keep things to your self, or brood about them, etc.) Past history Whether any type of disease you had in past (eg. Nembutal, Jaundice, Mumps, Typhoid, Recumbent cough & cold, any type of surgery, etc.) Family history Family history about any type of disease & when? (eg. Allergy, skin problem, asthma, cancer, diabetes, etc.) For Female Patients only.. Age of onset of periods Cycle RegularIrregular Interval between two periods in days: Physical or mental symptoms:Before periods: During periods: After periods: (eg. heaviness / pain in breast / change in mind, headache, backache, pain in legs, changes, in appetite, thirst or bowel, dreams etc.) Flow of bleeding (eg. heavy, scanty, moderate) Are you using any contraceptive pills? (Yes or No) Any discharge before / during / after periods No. of children: Male Female Delivery NormalCessarionAny abortion Age of onset of menopause Did the periods cease gradually or abrupt? Any mental or physical symptoms during or after menopause
