1. Presenting Complaints:
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Chief complaint:
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Describe every symptom in detail:
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Onset and duration:
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Chronology of symptoms:
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Diagnosis, if any, made by physician / specialist:
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What worsens / eases these symptoms?
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(Note:Kindly scan and attach any diagnostic
and other medical reports you may have
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2. Other Diseases or Complaints:
(Describe in the same manner as above)
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3. General Information :
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(Note: No detail is "too insignificant" or "medically irrelevant".
Of particular importance are recent changes you may have noticed in your appetite,
desire for or aversion to certain foods, sleep pattern, bowel habits, dreams etc.)
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(a.) Appetite:
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Average
Poor
Healthy
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Strong likes and dislikes for foods:
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Tendency to indulge in certain foods:
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Food allergies:
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(b.) Temperature - More
tolerant to:
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Cold
Heat
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Weather you are most comfortable in:
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Weather that makes you uncomfortable:
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Most comfortable outdoors or indoors:
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(c.) Perspiration:
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Do you perspire profusely?
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Yes
No
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If so, where and under what circumstances?
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Do you use any of these:
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Talcum powder
Deodorants
Perfumes
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(d.) Sleep:
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Quality of sleep:
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You wake up:
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Refreshed
Fatigued
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(e.) Dreams:
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Do you dream at all?
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Yes
No
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Do you remember your dreams?
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Yes
No
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What do you dream about?
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Do you have recurring dreams?
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Yes
No
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If so, state the content:
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(f.) Bowels:
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Frequency:
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Regular
Irregular
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Stool:
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Regular
Constipated
Loose
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Is your urine normal?
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Yes
No
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(g.) Thirst:
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Liquid intake:
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Low
Average
Good
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Do you feel thirsty all the time?
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Yes
No
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(i.) Personal Details:
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Weight:
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Lean
Average
Flabby
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Height:
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Tall
Short
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4. Family Background :
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Marital status:
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Living arrangement (whom do you live with?):
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Whom does your immediate family consist of?
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Your relationships with individual family members
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Position in sibling hierarchy:
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History of disease in the family, going as far back
as possible:
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5. Childhood History :
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Type of delivery:
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Complications during delivery:
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Developmental milestones:
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Normal
Delayed
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Vaccinations, including reactions:
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Childhood diseases:
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Your happiest / most painful childhood memories:
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Your childhood nature (timid, hyperactive, mischievous,
rebellious, etc):
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6. Milestones :
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Major events that have impacted you adversely:
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Accidents and injuries:
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7. Lifestyle :
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Addictions and habits:
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Do you exercise?
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Yes
No
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Do you like your job?
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Yes
No
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Recreational activities:
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Sex life:
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Social life:
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Spiritual life:
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8. Mind :
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Dominant emotional state:
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If predominantly negative, state probable causes:
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How do you express these negative emotions?
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How expressive are you?
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How sensitive are you?
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Disturbing or stressful factors in your daily life:
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Emotional factors that may have triggered your ill-health:
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What issues / events upset you most? Include past and
present. How have you adjusted / reacted to these events?
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Insecurities, disappointments or other issues in your
relationships (family, marital, work-related, etc):
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What are your greatest fears? Include past and present:
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Other Information :
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Any other information not covered above that could
be useful in evaluating you:
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Additional Information for Women :
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Age of onset of period:
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Regularity of period:
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Physical symptoms preceding onset of period:
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Duration of period:
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Interval between periods:
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Contraceptive method:
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Discharge before, during, after period:
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Number of children:
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Type of delivery:
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Post-delivery problems:
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Problems with breastfeeding:
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Any abortions and complications:
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Age of onset of menopause:
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Did your period cease abruptly or gradually?
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Surgery or other problems with reproductive system:
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