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50/2, Masih Garh,

Sukhdev Vihar Road,

New Delhi-110025

Phone:+91-9810486770

  • First time users should fill it thoroughly
  • At subsequent consultations, fill only Follow up Sheet.
  • Must fill your payment options and related details for confirmations.
  • All details regarding How to pay and Payment options are on Want Treatment ? page.
  • Medicines will be sent at your specified destination along with detailed instructions in case of “Consultation-with-medicine plans-within India”
  • Prescription will be sent on E-mail for “Only Consultation plans”- in case of “Within India” & “REST OF THE WORLD” patients

Patient History Sheet

TREATMENT PLANS:-

Must select your payment options and related details for confirmations. SELECT ONE TREATMENT PLAN. All details regarding *How to pay and *Payment options are on "Want Treatment ?" page. Medicines will be sent at your specified destination along with detailed instructions in case of "Consultation-with-medicine plans-within India

TREATMENT PLANS:-

Patient's Complaints/symptoms

MAJOR COMPLAINTS

with as much detail as possible -------
With aggravating and ameliorating factors,Intensity, frequency and duration of complaints,Overall distress caused by the complaints,Degree of daily life affected by complaints,Need of other medicines and accessory measures of relief.

MALE/FEMALE/SEXUAL SYMPTOMS

Relevant Menstrual details (Last M/c date, regular/irregular, heavy/normal/ scanty/ duration of flow, pre/ during/post M/c Complaints.Relevant Obstetric details – Pregnancy/Abortion/ Operation-details OR Male sexual symptoms

EMOTIONAL/MENTAL SYMPTOMS

About Yourself – Fears, Anxieties, anger, irritability, aggression, weeping, punctuality, cleanliness, obsessions, personality traits etc.
Toward family and society – Love, hate, jealousy, sympathy.
Toward disease – Hopefulness, despair, weeping, thoughts, etc.

DESIRES-AVERSIONS/LIKES-DISLIKES

Food & Drinks – Salt / sweet / sour / spicy / cold / hot / vegetarian / non-vegetarian / food
allergiesAddictions– alcohol / smoking / drugs / tobacco etc., if any
Weather & temperature – winter, summer, rain, autumn, change of weather & temperature

APPETITE-THIRST-URINE-STOOL-SWEAT

SLEEP-DREAMS-STAMINA-ENERGY LEVEL

PAST HISTORY -of medical and surgical diseases

Of medical and surgical diseases,Year & Details of Diseases and their treatment (Medical or surgical),,Emotional shocks, tragedy, bereavement, broken marriage, financial loss, major accidents etc

FAMILY HISTORY

Age and Diseases of Paternal Grand Father, Paternal Grand Mother, Paternal Uncles, Paternal Aunts, Maternal Grand Father, Maternal Grand Mother, Maternal Uncles, Maternal Aunts, Father, Mother, Brothers, Sisters, Cousins, Sons, Daughters

ALLOPATHIC MEDICINES

being taken on a regular or continual basis

LAB REPORTS

Blood Reports, X-rays, Ultrasound, Biopsy, Urine, Stool, E.C.G., Echo, MRI, CT Scan, Angiography etc. (you can attach photocopy of reports)Photograph of the diseased portion, if applicable.

LAB REPORTS

you can attach photocopy of reports.



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