Case Paper for Online Consultation

Case Paper for Online Consultation

Fill up this case paper & send on following mail  ID

sarpotdar.sachin@gmail.com

Ayurvedic Consultants –1) Prof. Dr.R.R.Deshpande &

                                     2)  Dr.Sachin Sarpotdar.                                                 

Personal Information –

Name-

Birth Date-                                                                              Age-                      Sex-              

 Height  in Centimeters-                                                        Weight in Kg

Address-

Website , Email address & Contact Numbers  -

Profession-                                                                      Working hours per day-

Marital Status-          

Number of Children-                           Sons-                   Daughters-

Spouse Profession-                                            

Dietary Pattern- 1)   Vegetarian-  Cooked / Uncooked /  Warm / Cold

                            2)  Non vegetarian -    Cooked / Uncooked / Warm/Cold

                                  Red Meat /week-

                                  White Meat / week-

                                  Fish / week-

Exercise- Details-

Personal Habits-

Alcohol types, frequency & amount per day- 

Smoking- Quantity / Day-

Other habits-

Physiological Functions-

A)    Appetite-

B)    Stool habits-

C)    Urine-

D)    Sleep-

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?

Family History-

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)

1)     Diseases

2)     Surgeries

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)

1)

2)

3)

4)

5)

6)

Present Medical History- Please Send a Scan Copies of these Documents if Possible.

Diagnosis ------------

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.

Visit us at – www.ayurvedicfriend.com