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Medical Questionnnaire
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Medical Questionnnaire

Kindly fill up the following details

 
Title  
Name of the Patient
 *
Gender
Age
*
Place of Residence
 *
E-Mail Id
 *
 
Chief Complaints
(Most significant sign of illness that caused you seek health care. Preferably in your own words and not in medical terms and do not mention your medical diagnosis)
    
Since     Delete
      
 
Allopathic Diagnosis in your condition if any
 
History of your present complaints
(Explain your present condition starting from the beginning of your problem in chronological order.)
 
Past Illnesses
 
Personal Information
Diet  
  special note if any  
 
App  

  special note if any  
 
Sleep  


  special note if any  
 
Day Sleeping Habit  
  special note if any  
 
Addictions / Habits if any  
 
Bowel Evacuations  
Every day
No of Evacuations a day
Time of Evacuation
Special note if any
 
Urination  

  special note if any  
 
Occupation  
 
Nature of Work  




  special note if any  
 
Current Medications
Medicine Name Intake Method Suggested For
(Write either the generic name or Brand name with mg) (The way in which it is taken. Example - one tablet twice daily after food) (Medical conditions for which it is suggested)
    
    
    
Delete
     
 
Treatment History
((Information about various treatments underwent for the illnesses)
Treatment Name Underwent During Special Note If any
    
    
    
Delete
     
 
Other Informations which you think might be helpful
 
Essential Lab Investigation values
 
Upload the essential/ latest lab investigation reports and other essential documents