Fill up this case paper & send on following mail ID
Ayurvedic Consultants –1) Prof. Dr.R.R.Deshpande &
2) Dr.Sachin Sarpotdar.
Personal Information –
Birth Date- Age- Sex-
Height in Centimeters- Weight in Kg
Website , Email address & Contact Numbers -
Profession- Working hours per day-
Number of Children- Sons- Daughters-
Dietary Pattern- 1) Vegetarian- Cooked / Uncooked / Warm / Cold
2) Non vegetarian - Cooked / Uncooked / Warm/Cold
Red Meat /week-
White Meat / week-
Fish / week-
Alcohol types, frequency & amount per day-
Smoking- Quantity / Day-
B) Stool habits-
E) Menstrual history- Regular/ Irregular
Heavy / Less / Normal.
F) Seasonal Tolerance – Spring/Summer/Autumn/ Winter.
G) Sun tolerance- Do you like to take Sunbath? How long You are comfortable?
Diseases in Family like- Diabetes, Heart Disease, Genetic problems, Allergy, Asthma, Arthritis & Cancers.- If Yes Please give details
Past Medical History- (If Yes please give details)
3) Drugs- e.g. Antbaby Pills – At what age and how many years.
Present Health Problems / Symptoms- (Since How long you have these health problems)
Present Medical History- Please Send a Scan Copies of these Documents if Possible.
Medicines Prescribed ---------------
Investigations and Findings -----------
Please see the list and mention if you have any symptoms from the list
Systemic Symptoms -
1) Gastrointestinal- Mouth Ulcers/ Gum bleedings/Nausea/Vomiting/Dysphagia/ Indigestion/Heart burn/ gases/Chang in bowel habits/ Abdominal pain.
2) Respiratory- Shortness of breath, cough, wheezing, chest pain, blood in sputum.
3) Cardiovascular- Chest pain, ankle edema, breathlessness, exertional dyspnea.
4) Nervous System- Headache, Dizziness, faints, fits, altered sensation, weakness, Visual disturbances, hearing problems, concentration problems, memory problems.
5) Endocrinal- Heat and cold intolerance, excessive thirst, changes in sweating
6) Musculoskeletal – Joint pain, stiffness, swelling, mobility,falls.
7) Genitourinary- dysuria ( Painful urination), Nocturia ( Increased night frequency), Hematuria (Blood in urine),Libido
8) Psychological- Mood Variations, Speech, Sleep disturbance ,Altered sensations, thoughts & behaviour.
9) Skin-Rashes, Sensory loss, Hypo & Hyper pigmentation
10) Ear- Pain, Discharge, Hearing problem, Tinnitus
11) Nose- Deviation, Secretion, Blocking, Loss of smell
12) Throat- Irritation, Hoarseness of voice
13) Ophthalmic- Vision loss, redness of eyes, secretions in eyes, Refractive errors, cataract, glaucoma.
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