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Please Fill in This Form For Our Chief Physician To Respond To Your Ailment

This document is a form for a patient to fill out providing information to a chief physician about an ailment. It requests information such as hospital number, patient and guardian name, contact details, age, gender, address, description of present complaints and their duration, details of previous investigations and treatments, current medications, allergies, past medical history, and dietary habits. It also asks whether inpatient treatment is required.

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Rajesh Nair
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64 views3 pages

Please Fill in This Form For Our Chief Physician To Respond To Your Ailment

This document is a form for a patient to fill out providing information to a chief physician about an ailment. It requests information such as hospital number, patient and guardian name, contact details, age, gender, address, description of present complaints and their duration, details of previous investigations and treatments, current medications, allergies, past medical history, and dietary habits. It also asks whether inpatient treatment is required.

Uploaded by

Rajesh Nair
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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PLEASE FILL IN THIS FORM FOR OUR CHIEF PHYSICIAN TO RESPOND TO YOUR AILMENT

Hospital Number, i a!"# (Please mention the Reference number allotted to you from the hospital) Name of the patient # Guardians Name # (In case of a minor) Organization Street !ity State !ountry Postal code "elephone #a$ %&mail I' lternate e&mail I' ge Se$ (eight )eight Structure
(Obese*+edium*,ean) #

# # # # # # # # # # # # # #

ddress

$O% DETAILS Nature of -or. and -hether it in/ol/es tra/eling

PRESENT COMPLAINTS ,ist of present complaints -ith duration of each SNo 1 2 3 4 5 6 '%S!RIP"ION '0R "ION

#ull (istory of present complaints7

'etails of in/estigations done so far7

'etails of treatments done7

!urrent +edication7

llergies7

(istory of pre/ious illnesses7 (Option) Past +edical (istory 'IS% S%S + , RI 'I 9%"%S #I,%RI : 0N'I!% PI,%S #IS"0, 0,!%R N% +I!

8%S

NO

OTHERS

Inpatient Treatment Required

8%S * NO

STATE OF DI&ESTION APPETITE %O'EL HA%ITS URINE (UANTITY SLEEP MENSTRUATION CYCLE FLO' ASSOCIATED 'ITH MARITAL STATUS 'eli/ery7 Problems if any Regular * Irregular Normal * ,ess * +ore Pain * !lots * +uscle cramps +arried * 0nmarried Normal * ,ess * +ore Regular * Irregular de;uate * ,ess * +ore de;uate * ,ess * +ore * 'isturbed

DIETARY HA%ITS S!(%'0,% % R,8 +ORNING 9R% = # S" +I' +ORNING ,0N!( %<%NING NIG(" ADDICIONS IF ANY Others please specify#

<egetarian * Non <egetarian +%N0 "I+INGS

Smo.ing *

lcohol * "obacco che-ing

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