PLEASE FILL IN THIS FORM FOR OUR CHIEF 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 : V. Kannan
Guardians Name
: K. Geetha (wife), K. Raghashri (daughter)
(In case of a minor)
Organization

Software consultant

Street Address

44/4, B-2/3, Sam Residency, Rukmani Street, Ground Floor

City

: Chennai

State

: Tamil Nadu

Country

: India

Postal code

: 600 003

Telephone

: 91-44-42668253

Fax

E-mail ID

: veekayg@hotmail.com

Alternate e-mail ID

: geet_k73@hotmail.com, geet.k73@gmail.com;

Age

: 42

Sex

: Male

Height

: 5.9

Weight

NA

Structure
(Obese/Medium/Lean) :

Medium

JOB DETAILS
Nature of work and whether it involves traveling
Ans: Desk work, traveling rarely in current position,
PRESENT COMPLAINTS
List of present complaints with duration of each
SNo
1
2
3
4
5
6

DESCRIPTION

DURATION

Full History of present complaints:

Details of investigations done so far:

Details of treatments done:

Current Medication:

Allergies:

History of previous illnesses: (Option)

Past Medical History
DISEASES
MALARIA
DIABETES
FILERIA
JAUNDICE
PILES

YES

NO

FISTULA
ULCER
ANEAMIC
OTHERS

YES / NO

Inpatient Treatment Required

STATE OF DIGESTION
Normal / Less / More

APPETITE

Regular / Irregular

BOWEL HABITS

Adequate / Less / More

URINE
QUANTITY
SLEEP

Adequate / Less / More / Disturbed

MENSTRUATION
Regular / Irregular

CYCLE

Normal / Less / More

FLOW
ASSOCIATED
WITH

Pain / Clots / Muscle cramps

Married / Unmarried

MARITAL STATUS
Delivery: Problems if any

DIETARY HABITS
SCHEDULE
EARLY MORNING
BREAK FAST
MID MORNING
LUNCH
EVENING
NIGHT
ADDICIONS
IF ANY
Others please specify:

Vegetarian / Non Vegetarian

MENU

TIMINGS

Smoking / Alcohol / Tobacco chewing