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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