PLEASE FILL IN THIS FORM FOR OUR CHIEF PHYSICIAN TO RESPOND TO YOUR AILMENT

Hospital Number, if any:(Please mention the Reference number allotted to you from the hospital)

Name of the patient : V. Kannan

Guardian’s Name : K. Geetha (wife), K. Raghashri (daughter)(In case of a minor)

Organization : Software consultant

Street Address : 44/4, B-2/3, Sam Residency, Rukmani Street, Ground Floor

City : Chennai

State : Tamil Nadu

Country : India

Postal code : 600 003

Telephone : 91-44-42668253

Fax : NA

E-mail ID : veekayg@hotmail.com

Alternate e-mail ID : geet_k73@hotmail.com, geet.k73@gmail.com;

Age : 42

Sex : Male

Height : 5.9

Weight :

Structure

(Obese/Medium/Lean) : Medium

JOB DETAILSNature of work and whether it involves traveling

Ans: Desk work, traveling rarely in current position,

PRESENT COMPLAINTSList of present complaints with duration of each

SNo DESCRIPTION DURATION123456

Full History of present complaints:

Details of investigations done so far:

Details of treatments done:

Current Medication:

Allergies:

History of previous illnesses: (Option)

Past Medical HistoryDISEASES YES NO

MALARIADIABETESFILERIAJAUNDICEPILESFISTULAULCERANEAMIC

OTHERS

Inpatient Treatment RequiredYES / NO

STATE OF DIGESTION

APPETITENormal / Less / More

BOWEL HABITSRegular / Irregular

URINEQUANTITY

Adequate / Less / More

SLEEPAdequate / Less / More / Disturbed

MENSTRUATION

CYCLERegular / Irregular

FLOWNormal / Less / More

ASSOCIATED WITHPain / Clots / Muscle cramps

MARITAL STATUSMarried / Unmarried

Delivery: Problems if any

DIETARY HABITSVegetarian / Non Vegetarian

SCHEDULE MENU TIMINGSEARLY MORNING

BREAK FASTMID MORNING

LUNCHEVENING

NIGHTADDICIONS

IF ANYSmoking / Alcohol / Tobacco chewing

Others please specify: