PLEASE FILL IN THIS FORM FOR OUR 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 :

Guardian’s Name :
(In case of a minor)

Organization :

Street Address :

City : Hanamkonda

State : Telangana

Country : India

Postal code : 506001

Telephone : +91

Fax :

E-mail ID :

Alternate e-mail ID :

Age : 75 years

Sex : Male

Height : 5 feet 6 inches

Weight : 1Kgs

Structure
(Obese/Medium/Lean) : Medium
JOB DETAILS
Nature of work and whether it involves traveling:
Most of the work is done by sitting at office. Minimum journey in car.

PRESENT COMPLAINTS
List of present complaints with duration of each

SNo DESCRIPTION DURATION

1 None None
2
3
4
5
6

Full History of present complaints:

Knee Pain since one year. No other issues other than this.

Details of investigations done so far:

X-ray of Knee

Details of treatments done:

Tablets and IFB(Physiotherapy)

Current Medication:
Normal, but facing severe pain in knees while walking

Allergies:
None

History of previous illnesses: (Option)

None

Past Medical History

DISEASES YES NO
MALARIA None None
DIABETES
FILERIA
JAUNDICE
PILES
FISTULA
ULCER
ANEAMIC
OTHERS None

YES / NO
Inpatient Treatment Required
No

STATE OF DIGESTION

Normal / Less / More

APPETITE
Normal
Regular / Irregular
BOWEL HABITS
Regular
URINE Adequate / Less / More
QUANTITY Adequate
Adequate / Less / More / Disturbed
APPETITE
Adequate

MENSTRUATION

Regular / Irregular
CYCLE
-
Normal / Less / More
FLOW
-
ASSOCIATED Pain / Clots / Muscle cramps
WITH -
Married / Unmarried
MARITAL STATUS
Married

Delivery: Problems if any

Vegetarian / Non Vegetarian

DIETARY HABITS
Vegetarian
SCHEDULE MENU TIMINGS
EARLY MORNING Water(1 ltr) 06:30
BREAK FAST Milk with Bread 08:30
MID MORNING - -
LUNCH Full Meals 02:00
EVENING Tea 04:30
NIGHT Two Chapathi 09:00
ADDICTIONS Smoking / Alcohol / Tobacco chewing
IF ANY None

Others please specify:None