DR JUGAL KISHORE S CLINICS
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1 DR JUGAL KISHORE S CLINICS DR. JUGAL KISHORE BSc., D.M.S., M.D. (HOM.) DR. ARVIND KISHORE M.B.B.S., M.F. (HOM.) Lond. CLINICS: 86 Golf Links, New Delhi Tel : , 17 Fax : docskishore@hotmail.com CASE RECORD PROFORMA CASE REFERENCE NO. DATE DIAGNOSIS NAME SURNAME FATHER S / MOTHER S NAME AGE SEX PRESENT WT. & HT. NATIONALITY MARITAL STATUS PROFESSION / OCCUPATION ADDRESS TELEPHONE/S FAX NO. ADDRESS
2 PRESENT COMPLAINTS (MAIN COMPLAINTS): ONSET ORIGIN OR CAUSE OF EACH COMPLAINT: PAST HISTORY (PREVIOUS DISEASES AND THEIR TREATMENT) FAMILY HISTORY (Give in detail if any of your blood-relatives i.e. parents, grandparents, siblings, aunts and uncles are suffering or have suffered from the following ): Allergies: Eczema Hay fever Sinusitis, Cold Allergic bronchitis Asthma Urticaria Arthritis: Gout Osteo-arthritis Rheumatoid arthritis
3 Cancer / Malignancy Diabetes Mellitus Hypertension Coronary Artery Disease, Angina etc. Tuberculosis Gonorrhoea / Syphilis or STD Psychiatric & Mental Disorders Schizophrenia Anxiety Neurosis / Depression Any other sickness not mentioned above? PERSONAL HISTORY Kindly elaborate and mention habits, addictions like alcohol, smoking, tobacco etc. Appetite : Are you vegetarian or non-vegetarian? Do you take eggs? Veg / Non-Veg Cravings in food: Mention grades of preference +, ++ or +++. For example if you love sweets, mention + or ++ or +++ Sweets Salty food Do you add Extra salt in your food? Sour things / pickles Seasoned and spicy Milk
4 Eggs Fried and fats Any other cravings in food? Do you dislike sweets or salty or any other specific food? How is your Digestion? Any complaints after eating? For example Fullness of abdomen, Gas formation or Diarrhoea after eating Do you feel bloated, full and heavy after eating? Can you remain hungry for hours on end without food? Do you get irritable with hunger? Does any item of food causes any discomfort eg. Acidity, headache, flatulance etc. Thirst: How is your thirst? Please mention the grade of thirst? If you are very thirsty, you may mention grades +, ++ or +++ How much water do you take at a time? How many times per day? Your preference in drinks: Please mention the degree of craving +, ++ or +++ Would you prefer cold / chilled water or drinks even in the height of winter? Would you like your cup of tea or coffee piping hot? Or just normal warm? How many cups of tea / coffee do you generally take in a day? Any aversion to any drinks? GENERALITIES State how you are affected by or how you react to the following: 1. Cold in general, cold air, drafts, cold winds etc. 2. Do you like to cover your head (or wear a cap) when you go out in the cold or when exposed to draft of cold air? 3. Warmth in general, warmth of bed or of room, external warmth like hot fomentation etc. 4. Weather: Dry, Cold wet, Rains, Cloudy etc. 5. Thunderstorms
5 6. Open fresh air 7. Near the sea / on mountains 8. Eating and Drinking (before, during and after) 9. Fasting 10. Any particular item of food / drinks which adversely affect you or make you sick 11. Closed, Crowded places, Elevators / Lifts etc. 12. Exertion or Physical strain, Mental strain 13. Lack of sleep 14. In what part of 24 hours do you feel the best or the worst? 15. Do your troubles tend to occur or become worse, periodically (eg. Daily or alternate days, every week, yearly, during new or full moon etc.) STOOL / BOWEL MOVEMENTS Do you regularly have a satisfactory bowel evacuation? How many times do you move the bowels? When? Consistency: whether Well formed Semi-formed Very hard Loose? Odour Colour of stool Any straining required or stool even though stool might not be hard or constipated? Any urgency for stools (eg. Do you have to run for stool first thing in the morning or immediately after eating? Any pain, burning, bleeding with stool? Piles / Fissure / Fistula? Do you have flatus (wind) when passing stool and is the stool noisy and spluttering?
6 URINE Frequency, day and night Any burning during urination? Any smell (Odour) in the urine? Any difficulty in passage of urine? Any difficulty in retaining urine? Do you have any incontinence while coughing or sneezing? Is the urine very urgent and you must rush immediately or it will escape? Any associated complaints with urination? SEXUAL SPHERE FOR MEN Any sexual disturbance? Excessive desire or aversion to sex Disability of performance, premature ejaculation etc. Night emissions Any history of sexual abuse, excessive masturbation etc. Any complaints after intercourse? FOR WOMEN Any sexual disturbance? Desire / Aversion to coitus? Any leucorrhoeal discharge? Itching, burning or discomfort associated? Any sense of bearing down at the time of menses? PREGNANCIES : How many times have you been pregnant? How many children do you have and their age? Did you have smooth pregnancies? Did you take any medication during pregnancy? Did you have normal deliveries? MENSES: Age of appearance of first period (Menarche) How are the periods? (regular or irregular) What is the duration of your period and how many days cycle? How is the flow? (scanty, heavy, clotted, any odour, colour) Any PMT (Pre-menstrual tension)? Do you have any complaints associated with, before or after menses? Eg. Moods, Headache, irritability, Anger, Weeping, Depression, Diarrhoea or Constipation
7 Any changes in your skin around menses? Any heaviness or pain in breasts before menses? Any nodules in the breast? MENOPAUSE: Age of menopause Any associated complaints at the time of menopause eg. Hot flushes, Palpitation, Anxiety, Depression etc. PERSPIRATION (SWEAT): Do you perspire a lot? Any particular part of the body that you perspire more on? Any strong / offensive odour associated (eg. Sour smell) with the sweat? Does the perspiration stain the clothes? SLEEP: Do you sleep well? Any particular posture in which you lie the most when you sleep? eg. Lying on the sides (right or left), back or on your abdomen, curled up etc. Do you feel refreshed after sleep? Do you dream while sleeping? Any particular dream that is recalled and often repeated? (eg. Frightening dreams of falling from a height, or being pursued by some men, or dead people or relatives etc.) Does any of your complaints get worse or better before, during or after sleep? eg. Cough or asthma attack that wakes you up at night or migraine on waking in the morning. Hot flushes just as you begin to fall asleep. SKIN: Any skin problems that you have or had earlier? (eg. Allergies, eczema, fungal infections, pigmentations, acne etc.) Any itching or discoloration associated with it? Any factors which worsen the skin problem? eg. Any item in food, any weather conditions or washing with warm or cold water. Any treatment taken for it and its details? Any complaints or abnormality of Nails or the skin around nails?
8 Any complaints of Hair falling, early greying, dandruff, thinning etc.? Any warts, moles, birth marks on the body? Does your skin heal normally after an injury or takes very long to heal? Any tendency to form excessive scar tissue (Keloids)? Any tendency for wounds to suppurate (form pus easly)? THE MIND: (It is very important to give as much details as possible in this section of the Proforma especially in Chronic diseases) Have you noticed any marked changes in your mental state lately? If so, describe it in detail please. Have you become or are- 1. Anxious / afraid of anything eg. Being alone, animals, darkness, disease, thieves, robbers, sudden noises 2. Do you get startled easily by sudden noises, telephone bells, banging of doors etc. 3. Suspicious, doubting 4. Impatient or hurried and hasty Do you eat hurriedly and there is always a sense of hurry? 5. Offended easily (cannot take any criticism) 6. Are you critical of others, always finding faults 7. Irritable, quarrelsome, violent etc. 8. Depressed easily, sad, gloomy 9. Timid / Shy / Bashful 10. Jealous or Suspicious 11. Anxious, restless, nervous or excitable 12. Do you feel very anxious and apprehensive before examination, before stressful situations, public engagements etc.? 13. Are you silent, quiet, reserved or talkative? Do you make friends easily? 14. Are you very affectionate? Do you demand love and warmth from others? 15. Do you cry easily? What makes you cry (grief of others, music kind words of affection etc.) 15. Are you very sympathetic in general and go out of your way to help people in need? Are you easily moved to tears at the plight of others?
9 16. If someone consoles you when you are upset, does it help or does sympathy towards you makes the matters worse? 17. How do stand and react to contradictions? 18. Are you an authorotative person, always in command and giving orders and expecting them to be followed by everyone around you? 19. Any imaginary fears or feelings? (eg. That someone might want to harm you or hurt you and that people are against you) 20. How is your memory, power of concentration and mental ability? 21. Do you feel humiliated or hurt easily? Would this give rise to any physical complaints? 22. Are you over conscientious about details, cleanliness, tidiness, punctuality etc.? Are you a perfectionist by nature, being meticulous, fastidious and even finicky? 23. What is the greatest grief that you have felt in life? Also what are the greatest joys in life you have experienced? 24. Can you mentally relax easily? For instance, can you switch your mind off work, problems, children etc.? Do you enjoy vacations? And can you totally relax when on a holiday or do thoughts of work or what is happening at home keeps bothering you etc. 25. At work or with colleagues, subordinates or your boss or seniors how do you equate with them? Would reprimand or scolding from them upset you tremendously? If so how? PREVIOUS TREATMENT TAKEN Disease Medicine Prescribed System of Therapeutics INVESTIGATIONS LABORATORY TESTS X-RAY, SCANS, MRI etc. others
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Montclair Homeopathy, LLC Linda Corenthal Robins, MD Holistic Homeopath 50 Belden Place Upper Montclair, NJ 07043 973-746-9888 www.montclairhomeopathy.com REGISTRATION FORM Name Age Date of Birth Address
What type of medication, vitamins, minerals, etc. are you currently taking? For how long? What for? (ie: Prilosec/6 months/acid Reflux)
What type of medication, vitamins, minerals, etc. are you currently taking? For how long? What for? (ie: Prilosec/6 months/acid Reflux) What previous methods have you tried to alleviate your discomfort
Headache Follow-up Visit Form
!1 Headache Follow-up Visit Form We will be unable to see you unless this form is completely filled out. We appreciate your thoroughness. Name DOB Age Today s Date Referring doctor: Primary doctor: Neurologist:
Essential Health Acupuncture Susana Byers, Lic..Ac. COMPREHENSIVE HEALTH HISTORY QUESTIONNAIRE
COMPREHENSIVE HEALTH HISTORY QUESTIONNAIRE PERSONAL INFORMATION Name Address City/Zip Home Phone Mobile Phone Business Phone Email Occupation May we email you? Yes No Today s Date Date of Birth Age Place
Medical History Intake Form
Medical History Intake Form What is your opinion of your overall level of health? Excellent Good Fair Poor In your opinion (not necessarily your health care providers), what are your most important health
Initial Consultation
Today s Date: Initial Consultation Thank you for choosing Apollo Health and Wellness. Please take your time to fill out this form. It will help us to concentrate on areas of your health that need attention
Metabolic Assessment Form
Metabolic Assessment Form Approach Wellness and Aesthetics 200 Forsythe Street Fayetteville, NC 28303 Office: (910) 322-7368 Fax: (910) 483-5796 www.tawellness.net Name: Age: Sex: Date: Part 1: Please
Health History Questionnaire
CLINICAL ACUPUNCTURE SERVICES Cathy D. Adelman, RN, LAc PO Box 91451 Tucson, AZ 85752-1451 (520) 822-6844 cdarnlac@hughes.net www.clinicalacupunctureservices.com Health History Questionnaire I. GENERAL
Gender: M F Race: Caucasian African American Hispanic Other
Weight Loss Surgery Patient Information First Name: Middle Initial: Last: Date of Birth: Age: Social Security #: Gender: M F Race: Caucasian African American Hispanic Other Address: City: State: Zip: Home
Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS
CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury
NMC PATIENT RECORD FORM. Your Details Title...Mr/Mrs/Ms/Other First Name Surname Address. Telephone number Fax number E mail address
NMC Natural Medicine Centre Richard Allport B.Vet. Med.,Vet.M.F.Hom., M.R.C.V.S. and Associates 11 Southgate Road ~ Potters Bar ~ Herts ~ EN6 5DR ~ U.K. Phone +44 1707 662058 ~ Fax +44 1707 646948 Your
PATIENT NAME: M.R. #: ACCT #: HOME TEL: WORK TEL: AGE: D.O.B.: OCCUPATION: HEIGHT: WEIGHT: NECK SIZE: GENDER EMERGENCY CONTACT: RELATIONSHIP: TEL:
SLEEP DISORDERS INSTITUTE HOSPITAL: DePaul Building Street Address City, State Zip Tel: (202) 555-1212 Fax: (202) 555-1212 SLEEP QUESTIONNAIRE PATIENT NAME: M.R. #: ACCT #: STREET ADDRESS: CITY: STATE:
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA 98136 206.200.3595 Today s date Name Legal name (if different) Phone (primary) (secondary) Address City State Zip Email
NEW PATIENT INTAKE FORM
NEW PATIENT INTAKE FORM Personal Information Name Date of First Visit Address City Province Postal Code Telephone # (home) (work) E-mail Address Relationship Status Age Date of Birth (M/D/Y) Gender: female
My energy is lower than I would like it to. I feel exhausted after exercising or physical activity.
SYMPTOMS Questionnaire Duplicate your answer across all of the 5 boxes that aren t blocked out. See example ENERGY My energy is lower than I would like it to be. I feel exhausted after exercising or physical
ADULT HEALTH HISTORY. May we you a monthly newsletter and/or other educational materials? Yes No
ADULT HEALTH HISTORY Name Date Address City State Zip code Phone, please circle your preferred number: (home) (cell) (work) E-mail Yes No (if you would like email appointment reminders) May we email you
WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS
WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS Prior to your office visit, we request that you complete this questionnaire. It asks questions not only about your sleeping habits and behavior
Name Date of Birth. Medical History Do you have any medical problems / major illnesses? Please list these with dates of diagnoses.
Name Date of Birth Medical History Do you have any medical problems / major illnesses? Please list these with dates of diagnoses. Regular Medications Please list all current prescribed medications and
Fertility HEALTH HISTORY
Fertility HEALTH HISTORY Female Name: First Middle Initial Last Preferred name Male Name: First Middle Initial Last Preferred name Address: City: State: Zip code: Contact numbers: home work/cell: Please
Medical condition SELF Mother Father Sibling (list brother or sister) Anxiety Bipolar disorder Heart Disease Depression Diabetes High Cholesterol
PRE-EVALUATION FORM Medical condition SELF Mother Father Sibling (list brother or sister) Anxiety Bipolar disorder Heart Disease Depression Diabetes High Cholesterol High Blood Pressure Obesity Heart Defect
Angela Berscheid RAc 02183; 697 Seedtree Rd, Sooke BC V9Z 1C2 (250) Patient Symptom and Evaluation Sheet
1 Patient Symptom and Evaluation Sheet 1. General Energy: normal low For how long?_ 2. Fever and Chills: fever chills alternating fever and chills fever in the afternoon all day evening dislike of heat
PATIENT INFORMATION. Name Today s Date. Address. City State Zip. Primary Phone # (h, w, c) Secondary Phone # (h, w, c)
PATIENT INFORMATION THANK YOU FOR CHOOSING BEAUTIFUL AMA! We are excited to work with you to balance your body and emotions naturally. These questions will help us develop an individualized diagnosis and
Allan Warshowsky MD,FACOG, ABIHM. New Patient Questionnaire Date of appointment :
New Patient Questionnaire Date of appointment : Name: Address: Apt# City: State: Zip: Phone: Cell: Email: Age: DOB: Referred By: Your occupation: Allergies: To Medications: Other: Reason for Today s Visit: