Case Record Form

We want to know you and your problems in detail. So In order to help you with the best medicine it is necessary for us to know about your problems and understand you as a person in as much as depth possible. Feel free to tell us everything minutely in detail and trust us that we will keep it confidential.

Name

Age

Gender

Male

Female

Other

Religion

Occupation

Marital status

Contact Number

Referred by

Present complaint and its details

When & How it started

What makes it worset

What makes it better?

Details of any other associated problems along with the main complain

Which weather is not tolerated by you or your problem?

At what time, season, and weather your problem is maximum or minimum

What is the most comfortable position for you during sleep?

Any unusual thing that happens to you like talking, teeth grinding or walking in sleep etc.

What do you like to eat or drink?

What do you dislike to eat or drink?

Any food item that gives you any problem

Any habits like smoking, sleeping pills, laxatives etc.

How many glasses of water you drink daily and cold/hot/lukewarm

Any complaint in urination or passing stool

Any sexual or personal problem you face

Male: Indulgence in past & present: Habit of masturbation, if any: Erection problem, if any

Any other sexual trouble: Inclination or attraction to same sex

Any problem related to periods (Only for Female)

At what age your menstruation cycle started and associated problem during that time

Pain or discomfort in body

Average cycle is of how many days

No. of days of bleeding

Bleeding character-(flow more/less-color clots etc.)

Any other changes before during & after Menses

Last Menstrual period was on

No. of pregnancies

No. of Childbirths

Method of deliveries

No of Abortions if any

Changes before and after deliveries & abortions; if any

Discomfort during or after making a sexual relation

Increased desire or dislike to sex

Any discharge per vagina, color, and stain, easy to wash or not

Maternal Family

Paternal Family

Past medical history

Any long illness, if ever had & treatment taken

Any allergic reaction to any food medicine or anything

Any Animal bite or anything like this & treatment taken

Fears

Dreams

Past Stressful Events

Childhood Memories (Good, Bad)

What Upsets You Easily?

What You Love To Do

What You Hate

What Makes You Happy

Happiest Moment Of Life

What makes you sad

Worst Memory Of Life

What Kind Of Life You Want

How You Think You Are Different From Others

Is there anything else you would like to communicate?