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PRESCRIPTION FORM.
Please read the following instructions carefully and fill in the all columns of
this form properly.
1. Please note that all the
information which you have provided in the form, will be kept in
strictly
confidential and shall not be provided or disclosed to any other third party at
any
cost.
2. Please print this form and
fill it with type or write very clearly.
3. Please fill all the columns of this form very carefully and properly.
This is you diagnostic
form and if you will provide wrong information, then I
will not be responsible for it.
4. If you require more space
then you may use separate sheets of paper.
5. Please
send me the photo copies of all you reports/tests and all other relative
material
which will be helpful in diagnose.
6. It will be better for you to
visit our clinic personally, if it is possible. Please take prior
appointment
over telephone or mobile.
7.
PLEASE FILL IN THE FORM IN ENGLISH OR URDU.
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1. NAME OF
PATIENT. MR./MRS./MISS.
2. AGE.
YEARS.
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3. SEX.
MALE/FEMALE.
4. OCCUPATION/PROFESSION.
5. RELIGION.
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6. MARITAL
STATUS.
7. NO. OF CHILDREN, IF ANY.
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8. COMPLETE POSTAL ADDRESS.
CITY.
Province/State.
Zip/Postal Code. Country.
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9. TELEPHONE # (WITH COUNTRY & CITY Codes).
10. EM@IL.
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11. DISORDER IDENTIFIED.
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12. SYMPTOMS.
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13. CONDITION.
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14. DRINK
ALCOHOL/WINE/CIGARETTES/
15. HOW MUCH? (WRITE QUANTITY).
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16. THIRST.
EXCESSIVE/LOSS/NORMAL.
17. APPETITE.
EXCESSIVE/LOSS/NORMAL. |
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18. COLOUR OF TONGUE.
RED/WHITE/YELLOW/THICK WHITE LAYER/THICK YELLOW LAYER/ |
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19. HOW MUCH TIME, THIS DISEASE STARTED? FOR THE
LAST
MONTHS/YEARS.
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20. ANY OTHER DISEASE. DIABETES. (MENTION YOUR SUGAR
IN FASTING & IN RANDOM SEPARATELY).
FASTING.
RANDOM.
HIGH BLOOD PRESSURE.
SYSTOLIC.
DIASTOLIC).
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21. PAIN. YES/NO.
EXCESS/LESS/NORMAL.
22. AT WHAT TIME? (MENTION TIME IF IT STARTS AT A FIX TIME OR IN
MORNING/NOON/EVENING/NIGHT).
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23. COMPLETE HISTORY.
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24. FAMILY HISTORY.
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25. SOCIAL HISTORY. (WHAT KIND OF PEOPLE/FRIENDS/RELATIVE
YOU HAVE? THEIR SEX? AGE? PROFESSION?
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26. ANY OTHER DETAILS.
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