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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.       

 

1.      NAME OF PATIENT.                                                                             

2.      AGE.                      YEARS.                   

3.      SEX.                         MALE/FEMALE.          

4.      OCCUPATION/PROFESSION.                                                                    5.      RELIGION.                        

6.      MARITAL STATUS.                                                                   

7.     NO. OF CHILDREN, IF ANY.                                   

8.     COMPLETE POSTAL ADDRESS.

                                                                                                                    CITY.

       Province/State.                                 Zip/Postal Code.                       Country. 

9.     TELEPHONE # (WITH COUNTRY & CITY Codes).                                             

10.    EM@IL.                                                                                             

11.    DISORDER IDENTIFIED.

 

 

 

12.    SYMPTOMS.

 

 

 

 

13.    CONDITION.

 

 

 

14.    DRINK ALCOHOL/WINE/CIGARETTES/                                         

15.     HOW MUCH? (WRITE QUANTITY).         

16.    THIRST.   EXCESSIVE/LOSS/NORMAL.                                   

17.     APPETITE.     EXCESSIVE/LOSS/NORMAL.

18.    COLOUR OF TONGUE.    RED/WHITE/YELLOW/THICK WHITE LAYER/THICK YELLOW LAYER/

19.    HOW MUCH TIME, THIS DISEASE STARTED?  FOR THE LAST                   MONTHS/YEARS.

 

20.    ANY OTHER DISEASE.   DIABETES. (MENTION YOUR SUGAR IN FASTING & IN RANDOM  SEPARATELY).

        FASTING.                                                 RANDOM.

        HIGH BLOOD PRESSURE.    SYSTOLIC.                                                            DIASTOLIC).

 

 

 

 

 

 

 

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).          

 

23.   COMPLETE HISTORY.

 

 

 

 

 

 

 

24.   FAMILY HISTORY.

 

 

 

 

 

 

 

25.   SOCIAL HISTORY. (WHAT KIND OF PEOPLE/FRIENDS/RELATIVE YOU HAVE? THEIR SEX? AGE? PROFESSION?

 

 

 

 

 

 

26.   ANY OTHER DETAILS.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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(If you want to give us any suggestions or corrections in this page, you may write the web master. Any suggestion or comments will be warmly welcomed).

site made & launched on internet on Sunday, July 25, 2004. 01:31:59 am.

last up dated Sunday September 26, 2004 08:23:33 PM

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