Krishnendu Ayurveda Hospital

Date-
Name
Nationality
Date of birth
Height (cm)
Weight (kg)
Sex
Occupation
E-mail address
Telephone #
Fax #
Marital status
Does your complaints aggravate During (please tick)
Exertion	Exercise	Normal activity
Any other	Rest
Past Medical History
Family History
Road Traffic Accidents
Surgery
Allergies to any medicine or food

Present complaint with duration (most serious problem first)

Symptoms with duration

If already diagnosed - details

Investigated details (if any)

Do you have any of the following

Type the Name of the above disease

Type Duration in Years/months/days(In figures)

Diabetes Mellitus

Duration

Current Medication

Hypertension

Duration

Current Medication

Heart disease

Duration

Current Medication

Elevated Cholesterol Level

Duration

Current Medication

Bronchial Asthma

Duration

Current Medication

Skin infection

Duration

Current Medication

Thyroid Problem

Duration

Current Medication

Hair falling

Duration

Current Medication

Enlarged Prostate

Duration

Current Medication

Cancer

Duration

Current Medication

Disk problems

Duration

Current Medication

Arthritis

Duration

Current Medication

Stroke

Duration

Current Medication

Sleep disorder

Duration

Current Medication

Stress

Duration

Current Medication

Mood change

Duration

Current Medication

Addiction to tobacco/alcohol

Duration

Current Medication

Osteopenia/Osteoporosis

Duration

Current Medication

Others

Duration

Current Medication

Investigation done – details if available
Diagnosis
Drugs prescribed with dose and how long taking them
Most recent tests done

X-ray Chest	Urine Analysis	Stool Exam
Colonoscopy	Lipid profile	PSA
Blood Sugar	H.crit	Bun
Uric Acid	Hb

Details of children

Male	Age
Female	Age
Adopted	Age
For Females (Menstrual Cycle)
Regular
Irregular
Menopause
Pap smear
Mammogram
Hot flush