CASE TAKING FORM

Date :_____________

Name :________________________________ Sex:_________ Age :_______________

Address:________________________________________________________________

Occupation :_________________________ Height :_________ Weight :____________

Chest :___________ Married :__________ Spouse Name :_______________________

Present Complaints :_______________________________________________________

When is the signs and symptoms of the present complaints appear first ? _____________

________________________________________________________________________

Which is the side more affected ?_____________________________________________

Appearance of the affected parts :____________________________________________

When is the disease felt more, time ?__________________________________________

Feeling of relief comes by :_________________________________________________

GENERALITIES

Complexion:___________________________ Face :____________________________

Scalp:__________________ Head:________________ Forehead :__________________

Eyes:__________________ Nose:_________________ Cheeks:____________________

Hair:__________________ Lips :_________________ Ears:______________________

Skin:__________________ Nails:_________________ Appetite:___________________

Thirst:_________________ Taste:_________________ Tongue:____________________

Throat:________________ Neck:_________________ Stools:____________________

Urine :________________ Abdomen:_______________ Others:___________________

Continue from page 1 CASE TAKING FORM

Anxious , worried, cheerful, sad, shy , etc ?_____________________________________

Bad habits, if any? ________________________________________________________

Memory :__________________________ Thoughts :____________________________

Mild, yielding or irritable, quarrelsome, jealous, etc.:_____________________________

Liking/disliking for sweat/ saltish_______________ Chilly/Hot_____________________

Liking/disliking for cold/warm food __________________________________________

Liking/disliking for cold/warm drinks _________________________________________

What type of season suits best? ______________________________________________

Which type of season is uncomfortable?:_______________________________________

Which type of season/climate aggravates the disease? :____________________________

Whether likes to remain in closed room or in open air, even if the cold open air? _______

________________________________________________________________________

Any kind of discharge ( indicate either thick , thin , white, yellow, bloody, green, blue,

Etc) ?
________________________________________________________________________

History of any previous illness? ______________________________________________

History of TB, Cancer, etc in the family ? ______________________________________

( both maternal / paternal ) ? ________________________________________________

Continue from page 2 CASE TAKING FORM

ADDITIONAL INFORMATION TO BE GIVEN BY THE FEMALE PATIENTS

Menses: (a) When appeared first?:___________________________________________

(b) Any complaint since then ?_______________________________________

(c) Present position _______________________________________________

(d) Are they painful and how the pain is relieved ? _______________________

_____________________________________________________________

(e) What is its colour ? Bright red, dark, brown, black, clotted, etc ? _________

______________________________________________________________

(f) Complaints during, before and after menses, if any ? ___________________

_____________________________________________________________

(g) When does it flow more ? _______________________________________

(h) How long it remains ? __________________________________________

Leucorrhoea :

(a) Whether thick or thin ? _________________________________________

(b) Bland or acrid ? _______________________________________________

(c) Cold or hot ____________________ (d) Colour ? ____________________

(d) When does it flow more ? _______________________________________

Any other information, such as any complaint since last delivery, painful coitus, sexual

desire, etc ? ______________________________________________________________

 TREATMENT PROGRAM

DATE MEDICINE PRESCRIBE DATE MEDICINE PRESCRIBE

 DESCRIPTION OF SYMPTOMS

RUBRICS