Dr. Jitendra Shukla
Dr. Jitendra Shukla
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Case History Form Hindi
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Book Now
Dr. Jitendra Shukla
Menu
Home
Treatments
Book Appointment
Book Appoinment for Online Consultation
Book Appoinment for Offline Consultation
Case History Form
Case History Form Hindi
Case History Form English
Downloads
Case History Form English
Case History Form Hindi
Contact us
📝 Dystonia Disease – Case History Questionnaire
📝 Dystonia Disease – Case History Questionnaire
📌 Patient Information
Name:
Age:
Gender:
Mobile Number:
WhatsApp Number:
Email (if any):
Full Address:
Pin Code:
🧠 Chief Complaints
1. What symptoms are you experiencing?
(e.g., muscle spasms, abnormal twisting or postures, neck turning, hand/finger cramping, excessive blinking, facial distortion)
2. Which part(s) of the body are affected?
Neck (Cervical Dystonia)
Eyes (Blepharospasm)
Face (Oromandibular Dystonia)
Hand/Fingers (e.g., Writer’s Cramp)
Legs/Feet
Whole body
3. Since when are you experiencing these symptoms? (Duration in months/years)
4. Are the symptoms constant or intermittent?
Continuous
Come and go
5. Do symptoms worsen during any specific activity?
Yes
No
🧍 Nature of Symptoms
6. Do you experience pain along with spasms or twisting?
Yes
No
7. Do the symptoms continue while you’re sleeping?
Yes
No
8. Do the symptoms reduce when distracted or in a relaxed position?
Yes
No
9. Are the symptoms limited to one side of the body?
Yes, only one side
Both sides
Vary/change
🧾 Medical and Family History
10. Have you consulted any doctor for this condition?
Yes
No
If yes, please share treatment/medicines and response:
11. Is there a family history of dystonia or any neurological disease?
Yes
No
If yes, please specify the relation:
12. Do you have any other medical conditions?
Diabetes
Thyroid disorder
High blood pressure
Mental stress/depression
🔬 Investigation History
13. Have you undergone any of the following investigations?
MRI Brain/Spine
CT Scan
Blood Tests
If yes, kindly share the reports via WhatsApp/email.
💬 Additional Information
14. Are you able to perform your daily routine tasks independently?
Yes
No
15. Do you have difficulty maintaining balance while walking?
Yes
No
16. Have you had any recent trauma, emotional stress, or major surgery?
Yes
No
If yes, please describe:
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