Case History Form English

Patient Reg. No-

Patient Name-

Gender-MaleFemale

Age-

Marital Status-MarriedUnmarried

Occupation-

Email Address-

Mobile No-

What's App No-

Alternate No-

Address-

House No/Village/Mohalla-

City-

State/Province-

Pin Code/ZIP/Postal Code-

Country-

Landmark-

Post Office-

PRESENT COMPLAINTS WITH DURATION OF EACH COMPLAINTS/SYMPTOMS IN DETAIL-

DISEASE AGGRAVATION FACTORS INCREASE IN DISEASE,PAIN OR ANY SYMPTOM OF DISEASE-DAY/NIGHT/TIME/CHANGE OF WEATHER/ANY SPECIAL SITUATION & CONDITION ETC.)-

DISEASE AMELIORATION FACTORS RELIEF IN DISEASE SYMPTOMS IN ANY SITUATION/CONDITION ETC.-

PRESENT ALLOPATHY/ANY OTHER TREATMENT WITH PRESCRIPTION & MEDICINES,DOSES-

PREVIOUS TREATMENT TAKEN TILL NOW SINCE BEGININING WITH EFFECT AND SIDE EFFECTS-

DOCTOR'S Name / HOSPITAL NAME WITH TREATMENT PERIOD & Effect/Side effect-

DOCTOR OPINION ABOUT DISEASE-

SHARE MEDICAL INVESTIGATION REPORTS-

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Share Video of 3 minutes of Patient Explaining Disease problem . Points to be covered IN VIDEO-Date & PATIENT REGISTRATION NO. EXPLAIN YOUR PROBLEMS IN DETAIL IN THE 2-3 MINUTES 2-3 VIDEOS OF PATIENT SUFFERING SINCE BEGINNING OF DISEASE.DESCRIBE YOUR EXACT DISEASE SYMPTOMS.-

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PATIENT CAN VISIT US AT OUR CLINIC IN FUTURE DURING TREATMENT FOR BRAIN FUNCTION & DISEASE RELATED BLOOD TESTS, FUNCTIONAL MRI OF BRAIN, F-DOPA PET SCAN, EMG, NCV, EEG AND OTHER INVESTIGATIONS BY TAKING PRIOR APPOINTMENT.

Dr. Jitendra Shukla Sanjeevani Homeopathy

Address: Shop No. 209, 2nd Floor, Felix Square, Above ICICI Bank, Near Lu Lu Mall Road, Sector B, Sushant Golf City, Lucknow - 226030

Clinic Timings: 10 AM to 7 PM

Helplines: 9305555066 | 9305055558 | 9336665554

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Dr. Jitendra Shukla

Dr. Jitendra Shukla

Case History Form English

Dr. Jitendra Shukla

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