This information is confidentially sent to Dr. Upasani to diagnose your problem and contact you. This information is never shared with anyone else.

Your Name*

name of the patient

Age *

age of the patient


To understand exposures of dust,chemicals,stress at the work place

Mobile number *
Email address *
Chief Complaint *

patients main complaints which he/she is suffering from

Onset of symptoms

How the complaint starts

SneezingRunning NoseBodyacheSoreness of ThroatHoarseness of voice

Aggravation and Amelioration of the symptoms

When the complaints increases or reduces

Climate changeWintersRainy seasonSummersDay timeAfternoon timeNight timePollinationPollutionSmokeCold drinks or cold foodStressSweet food itemsSour food itemsNear Sea

Associated Complaints

Complaints with your main complaints

BreathlessnessNose blockLoss of SmellWatering of eyes with burningWatering of eyes without burningCoughWheezingHeadacheBleeding from NoseVomitingFeverBodyache

Cough Type
Dry CoughCough with Loud soundWet Coughwith yellow mucouswith green mucouswith white mucous
Fever Type
High FeverLow grade FeverEvening rise of temperaturewith Bodyachewith Weaknesswith Thirstwithout Thirstwith Chills
morelessmoderatewith Bodyachewith Weaknesswith Thirstwithout Thirstwith Chills
Tolerance of the climate

which type of climate you can tolerate more


If having Asthma details of Asthmatic attacks
History of Major Ilnesses in the Past
Family History of illnesses

To understand the familial tendencies of illnesses for e.g. Allergies

Previous and Current medications details
Allergies and side effects of any medicines
Details of Allergy Tests done if any
Details of Lung Volume Study done if any
Details of X-Ray, CT scan, MRI scan is done if any
Other Investigations

like sputum examination, culture, T.T.

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