ONLINE PATIENT CONSULTATION FORM Download Form
 Patient Name:
 Address:
 Phone No.:
 Email:
 Age:
 Sex: Male    Female
 Occupation:
 Chief Complaints:
 Past History:
 
Similar Trouble Typhoid Malaria
TB Jaundice Pneumonia
Diabetes Skin Disease  
 Any Other Disease:
 Previous T/T :
 OB/H History:
 Nature of delivery:
 No & Age of Children:
 Complications during
 labour if any:
 Menstrual History:
 Family History:
 Personal History:  
 Appetite:
N M L
 Thirst:
N M L
 Any food which disagrees:
 Desires:
Sweet Spicy Sour Bitter Warm Cold
 Aversion:
Salt Meat Milk Juicy Fruits Indigestible Eggs
 Bowels:
Regular Constipation Loose stools
 Type of Stools:
 Urine:
 Flatulence:
 Sweat:
 Sleeps:
 Dreams:
 Addictions:
Alcohol Tea Coffee Tobacco Drugs
 Thermals:
Chilly Hot
 Mental:  
 Memory:
Active Quick Witty
Fearful Timid Coward
Haughty (Pride) Graceful (Well dressed/descent)
Conscious diligent Positive/ Confidence  
Anxiety of Consciousness (Whether accepts mistake or not)
Sadness/ Moroseness (moodiness/ resentment)  
 Sensitivity:
Noise Touch Light Criticism
 Disposition:
Affectionate Angry Talk dispose to
 
Cheerful Vivacious Responsible
   
 Physical Examination:
 General:
 Pulse:
 B.P
 C.V.S:
 R.S:
 C.N.S:
 ABDOMEN:
 LOCOMOTOR:
   


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