Consultation Form Consultation Form Name* First Last Age*Email* BirthdateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex*SexMaleFemaleMarital StatusMarital StatusMarriedUnmarriedWidow/erHeightWeightWeight valuelbs (Pounds)KgsOccupation (Type of work)Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Residence Phone NoOffice Phone NoPhone NoPresent ComplaintsMention the complaints you are suffering in your own words. Please describe fully the troubles, including its origin, subsequent development and effects of treatments that were received. In this description, please be certain to cover at least the following points for individual complaints: :: Area of body affected and when :: Sensations and pains experienced :: Circumstances (physical & emotional that you feel have brought on the trouble) :: Conditions that increases the trouble :: Conditions that reduces the trouble :: All other accompanying troublesMain problems/reasons for this consultation: (If possible, rank in terms of importance to you)Additional problems or concerns you would like to address*Note: we may not be able to address every problem during the course of single treatmentCurrent Medications Dose Times/day Current Herbs/Vitamis/Homoeopathy/Supplements Dose Times/day Past History(Medical/Surgical diseses suffered in the past or any trauma/injury/hospitalization incurred) Disease/Injury suffered Approximate Age Duration Whether you completely recovered Medicines & treatment taken Any other Particulars Family History(Kindly mention any diseases suffered/suffering from by your family members (Spouse/Blood relations)RelationFatherMotherGrand FatherGrand MotherSonDaughterBrotherSisterPaternal unclePaternal auntMaternal uncleMaternal auntOthers: specifyIf Others: specify in detailFather's InformationDisease sufferedDurationPresent statusOn treatmentCuredMother's InformationDisease sufferedDurationPresent statusOn treatmentCuredGrand Father's InformationDisease sufferedDurationPresent statusOn treatmentCuredGrand Mother's InformationDisease sufferedDurationPresent statusOn treatmentCuredSon's InformationDisease sufferedDurationPresent statusOn treatmentCuredDaughter's InformationDisease sufferedDurationPresent statusOn treatmentCuredBrother's InformationDisease sufferedDurationPresent statusOn treatmentCuredSister's InformationDisease sufferedDurationPresent statusOn treatmentCuredPaternal Uncle's InformationDisease sufferedDurationPresent statusOn treatmentCuredPaternal Aunt's InformationDisease sufferedDurationPresent statusOn treatmentCuredMaternal Uncle's InformationDisease sufferedDurationPresent statusOn treatmentCuredMaternal Aunt's InformationDisease sufferedDurationPresent statusOn treatmentCuredOther Specified InformationDisease sufferedDurationPresent statusOn treatmentCuredPersonal HistoryYour habitsSmokingHow muchSinceAlcoholHow muchSinceCoffeeHow muchSinceTeaHow muchSinceTobaccoHow muchSinceSleeping pillsHow muchSinceLaxatives/Purgatives/other drugsHow muchSinceAppetite & ThirstHow is your appetite?Have your appetite/thirst intake changed after illness?How much thirst do you have?Any change of taste in your mouth?What are the foods or drinks you like?What foods or drinks make you worse?StoolDo you have any problems regarding your stools?Do you have belching or passing of gas?Urination & UrineSexual SphereAny problems regarding urination or urine?Any problems relating to sex or sexual organs?Sweat/PerspirationHow much do you sweat?Do you perspire on the palms or soles?Any symptom relating to sweating?MiscellaneousHow is your tongue-clean or coated?What about tonsils, adenoids and polyps in nose?What about salivation?What about sleep?Any complaints occuring Off & On?Additional information if any?What kind of weather are you most comfortable in?Are you particularly uncomfortable in any weather or climate?Do you like to be in open air or do you feel more comfortable in a closed room?About your routineTypical breakfastTypical lunchTypical dinnerTypical snacksDevices you useEyeglassesContact lensesHearing aidDenturesIntra-uterine devicesPacemakerProstheticsMilestones of Life Birth history, Trying to sit up, Teething, Walking, Talking, etc. (Whether on time, early, delayed or if any incidences associated with it)Additional Queries (applicable only for Female Patients)Age at onset of periods (Menarche)*Last Menstrual Period (LMP) Date Format: DD slash MM slash YYYY Duration and interval between periods (Eg. Flow for 3-5 days and interval between period is 28 days)Physical symptoms preceding the onset or following periods? (Eg. Pain in legs, heaviness/pain in breasts, changes in bowel habit, appetite, moods, headache, particular dreams, etc.)Periods Regular?YesNoAny white discharge before/during/after periods?BeforeDuringAfterNoneAre you using any contraceptive tools?YesNoif yes, detailsType/character of discharge?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?Age of onset of menopauseDid the periods cease gradually or suddenly?GraduallySuddenlyHave you had any operations done in the pelvic area?YesNoif yes, detailsInvestigations undergone (Kindly address the most recent readings)Investigation name Investigation on Findings (Unfilled details may be considered either to be negative, non-contributory and/or non-pertinent) (You may be asked some more details if required to arrive at a complete workout of a case)
