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Husband's Name
*
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*
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*
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*
Wife's Name
*
Age
*
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*
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*
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Details About Married Life
Years
*
Husband
*
First Marriage
Second Marriage
Third Marriage
Wife
*
First Marriage
Second Marriage
Third Marriage
Coition
(Sexual Intercourse)
Continuous
Frequently
Others
Treatment History
Details below are not mandatory
Male Partner
History of Past Illness
Tuberculosis
Mumps
Infections of Genital Organs
Others
Others, please specify
H/O drugs intake (medicins)/Radiation etc
H / O Any Surgery
Tobacco Addiction
No
Yes
Alcohol Addiction
No
Yes
Drugs
No
Yes
Appetite
Normal
Increased
Decreased
Thirst
Normal
Increased
Decreased
Craving of any food items
specify as salt, sweets, sour, chillies, cold/hot, etc
Aversion/ Allergy for any food items specify
Perspiration
Normal
Increased
Decreased
Any parts specify
Offensive / Sour smell / Non Offensive
Urine
Normal
Increased
Decreased
Pain/Smell
Type of Pain / Smell
Motion
Normal
Increased
Decreased
No of times/Day
Preferred Climate
Takes Bath in
Hot Water
Cold Water
Body Feels
Warm
Cold
Family History
(Detailed description of Father, Mother, Brothers, Sisters, Uncles, Aunts, Grandparents, Children with their age and any relevant diseases (Blood pressure, Diabetes, Hepatitis, Tuberculosis, Cancer, HIV Infection, Tumors, Arthritis, Skin diseases, etc.)
Mind
(Patients reaction towards the society, family, and friends. Whether irritable, anxious, tensed, suspicious, likes company of friends, brooding, any suicidal thoughts, etc.?)
Sleep
Female Partner
History of Past Illness
Any diseases which occurred in the past like tuberculosis, hepatitis, typhoid, arthritis etc., may be described in detail in sequential order. Also specify any other diseases from childhood down to the present, chronologically with its nature, duration, severity, type of treatment undergone etc. in detail.
Family History
(Detailed description of Father, Mother, Brothers, Sisters, Uncles, Aunts, Grandparents, Children with their age and any relevant diseases (Blood pressure, Diabetes, Hepatitis, Tuberculosis, Cancer, HIV Infection, Tumors, Arthritis, Skin diseases, etc.)
Age of Menarche (First Menses)
Past
Present
Problems if any?
(pain, vomitting, diarrhea, fever, vertigo)
History of H/O miscarriage or abortion, if any
Addiction to Tobacco
No
Yes
Alcohol
No
Yes
Drugs
No
Yes
Appetite
Normal
Increased
Decreases
Thirst
Normal
Increased
Decreased
Craving of any food items
Specify as salt, sweets, sour, chillies, cold/hot etc
Aversion/Allergy for any food items specify
Perspiration
Normal
Increased
Decreased
Any parts specify
Offensive / Sour smell / Non Offensive
Urine
Normal
Increased
Decreased
Pain/Smell
Type of pain/type of smell
Motion
Normal
Increased
Decreased
No of times/Day
Preferred Climate
Take Bath in
Hot Water
Cold Water
Body feels
Warm
Cold
Mind
(Patients reaction towards the society, family and friends. Whether irritable, anxious, tensed, suspicious, likes company of friends, brooding, any suicidal thoughts etc.?)
Sleep
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WE WISH YOU ALL A HAPPY ONAM OUR CLINIC WILL BE CLOSED ON SEPTEMBER 16th AND 17th (2 DAYS) AND WILL REOPEN ON 18 th,ഏവര്ക്കും ഓണാശംസകള് സെപ്റ്റംബർ -16 ,17 (,തിങ്കള്,ചൊവ്വ)ക്ലിനിക് മുടക്കം ആയിരിക്കും