Consult

Your Name*

name of the patient

Age *

age of the patient

Gender*
MaleFemale

Occupation

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

Thirst
morelessmoderatewith Bodyachewith Weaknesswith Thirstwithout Thirstwith Chills

Tolerance of the climate

which type of climate you can tolerate more

ColdHotModerate

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.