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Sunday, 9 March 2014

Case Paper for Online Consultation

Case Paper for Online Consultation- Download Form
(Right click and -Choose" Save link as...") download it and fill.Then send as attachment to sarpotdar.sachin@gmail.com

Fill up this case paper & send on following mail  ID

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.

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