ConfidentialPage 110/28/2018

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Care ‘n’ Cure Health Clinic

#269, 1st Floor, 2nd Cross, 3rd Main, Cambridge Layout, Shirdi Sai Baba Mandir, Road, Ulsoor, Bangalore, Karnataka, India-560008

Phone : +91-80-25561088

Email:

Please fill in this case sheet to help us treat you better. Email or snail mail this case sheet to us to the addresses given above.

CASE SHEET FOR OBESITY

PERSONAL DETAILS

Name : ______

Age : ______

Sex : ______

Occupation : ______

Address : ______

______

______

Tel No : ______

E-mail ID: ______

PRESENTING COMPLAINTS

  1. Since when did the complaint start?
  2. Is anybody in your family obese other than you?
  3. Do you have the habit of eating snacks?
  4. Are you a vegetarian or non-vegetarian?
  5. What is your present weight and height?
  6. Which are the main area(s) that you are gaining weight?
  7. Which shampoo and oil are you using presently?
  8. Do you have any other health related complaints like Thyroid problems, Diabetes, Hyper Tension, etc?

Associated Complaints – Any gastric complaints,dust allergy, any headache you get when exposed to sunlight or any other health wise problems you are suffering along with the above complaints?

HISTORY

  1. Did you have any illnesses in childhood like Jaundice, Typhoid, Chicken Pox, Malaria, Pneumonia, etc?

FAMILY HISTORY

  1. Does anybody from your family members including your parents and grand parents have /had any health related problems like High/Low Blood Pressure, Diabetes, Arthritis, skin complaints, asthma, pneumonia, tuberculosis, cancer etc?

TREATMENT HISTORY

  1. Have you undergone treatment for serious illness in the past? – like Asthma, Dysentery, Tuberculosis, Typhoid, Diabetes, Malaria, Hypertension or some problems of the skin such as Eczema, Psoriasis, Ring-worm, Urticaria, Measles, Mumps, Herpes, Chicken-pox etc.,
  2. Have you undergone any surgeries/operations/Injuries in the past?

GENERAL HISTORY

  1. How is your food intake? Veg. or non veg?
  2. Do you skip food?
  3. How many glasses of water do you drink every day? Do you prefer hot water/cold water/normal water?
  4. How is your sleep .do you cover yourself with bed sheets? How? legs only or entire body. Do you feel fresh on waking up? The position you prefer to sleep in? eg. on back, on stomach etc.
  5. Do you have any urinary complaints or infection?
  6. Do you sweat very much? If yes, which are the areas of your body that sweat more? Any offensive smell?
  7. Do any of your body parts feel more hot/cold? If yes, which are the areas?
  8. Which climates do you like most?
  9. Do you have any addictions like smoking, drinking, coffee, tea etc?
  10. Are you suffering/suffered from constipation or hardness of motion?
  11. Do you like to put fan ?if so in what speed full speed or medium speed.or do you avoid putting fan in full speed due to some health problems or discomfort?
  12. Any addictions like smoking, drinking alcohol, chewing tobacco, pan masala .if so since how long?
  13. Any peculiar habit of washing hands several times or checking the door at night etc.?

Which climate you like most summer winter medium .why you like that climate.

Do you like sweets,salty,spicy,ice cream,juice, milk[plain milk] or flavoured milk as per your real nature.or whether you avoid those things because of any particular reason?. Any like or dislikes or avoid for the above.

do you like plain milk without any flavour if you are offered?

(please clearly mention whether you 'like' or 'dislike' or 'disagree' or 'avoid' the following )

Bitter Salt Extra Sweet

Sour Bread

Butter Fats plain Milk

Fish Chalk

Eggs Spicy Food Meat Fruits

Cabbages

Onions Warm food- Drink Cold Food-Drink Anything Else:

MENSTRUAL HISTORY (ONLY FOR FEMALES)

  1. What was the age when you got your first menses?
  2. Is your period regular?
  3. How many days do your period last?
  4. Is there any clots or whitish discharges?
  5. Are there any other associated complaints associated with periods like backache, headache, etc?

OBSTETRIC HISTORY (ONLY FOR FEMALES)

  1. How many children do you have?
  2. Did you have a normal or caesarian delivery?
  3. Any abortions/miscarriage/forceps deliveries?

BRIEF PERSONALITY PROFILE

About your mental state and your emotional nature. Please answer in this part about your situation in life and about all the things that are bothering you. Kindly be frank and open)

How do you describe yourself as a person? (Min 200 words please)

Are you punctual by nature.do you keep time schedule.do you complete work in time without pending?

Do you try to finish the work in time or keeps postponing?

How is your confidence level?

How good your studies average or above average? How good you are/were in mathematics?

Are you particular about cleanliness and neatness?

Are you anxious about which matters?

Are you reserved or extrovert by nature.do you make friends fast or selective friends?

Any stage fear or exam fear initially or throughout?

Are you fearful of anything such as Animals People Being Alone Darkness Death Disease Robbers Sudden Noise Thunder Of the Future Of something unknown

High places Timidity or any other Are you doubtful or suspicious? of
what?

Unpleasant experiences. (Disagreements, Humiliation; Fights; Deaths; Separations; Divorce, Monetary Loss in business or losing a job, love affair failure etc.)

If you are scared of any animals, insect, darkness height, water, robbers etc. (mention of childhood fears too)

What are you jealous about? of whom ? , From what symptoms do you suffer when jealous?

In which matters are you impatient? Hurried?

How long do you remember hurts came to you by others? Offended easily?

How much revengeful are you?

What are you proud of?

Does your pride get easily hurt? (Egotism)

Depressed/Brooding etc.?

Do you ever become suicidal ? Yes No

When?

If so in what manner do you contemplate to end your life?

Even then are you afraid of dying ? Yes

When are you cheerful?

Any unwanted thoughts any time? What are they?

Have you any imaginary sensations or fears?

Do you hear voices as that you are called or anything else in this line keeps on occurring in your mind unduly? Yes No

How is your memory?

For what is poor? e.g. names, places, faces, what you have read, etc.

Do you weep easily Yes No

What makes you weep?

How do you feel after weeping?

How do you feel if someone offers sympathy and consolation?

Are you easily irritated? Yes No

What makes you angry?

What bodily symptoms do you develop when angry ? , e.g. trembling, sweating etc.

Do you like company ? or like to remain alone ?

How seriously are you affected by disorder and uncleanness in your surroundings ? Yes No

What are the greatest grief’s that you have gone through in your life?

What are the greatest joys that you have had in life?

What activities you deeply like?

Are there any matters which you deeply dislike?

In your opinion, which aspects of mind and moods are not agreeable to you. In spite of your awareness and maturity, are unable to change this aspect?

Give a clear cut picture of your situation in life and your relationship with each of your family members, friends and associates in work.

How does the future look to you?

Are you transparent/open minded by nature? Or are you a closed person?

This document is the sole proprietary of Care ‘n’ Cure Health Clinic. Any part of this document should not be re-produced in any format without prior approval.