*
Name :
Age :
*
Sex :
Occupation :
Address :
*
E-Mail :
Present complaints and duration :
History of the present illness :
History of any major diseases before :
Personal History :
Appetite :
Normal
Less
High
Sleep :
Normal
Less
More
Bowel Movements :
Normal
Constipated
Loose
Urine :
Normal
Less
More
Burning
In abnormal case please specify :
Sexual Drive :
Normal
Abnormal
Height :
Weight :
Blood Pressure :
Habit :
Menstrual History :
Mental Functions
Pleasure :
Normal
Low
High
Sadness :
Present
Absent
Fear :
Present
Absent
Anger :
More
Less
Depression :
Present
Absent
Treatment history, Medical reports
& Lab investigations :
Family History
Parents :
Alive
Dead
If dead, due to :
Marital Status :
Children :
History of any specific disease in the family :
Other specifications related to the disease :
