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    Patient Information Form

    Uploaded by

    Tarek khan
    Case taking format

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Patient Information Form

    Uploaded by

    Tarek khan
    2 views3 pages
    Case taking format

    Original Title

    Patient_Information_Form

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

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    Case taking format

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    2 views3 pages

    Patient Information Form

    Uploaded by

    Tarek khan
    Case taking format

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    Patient Information Form

    Personal Details
    Name:

    Age:

    Gender:

    Occupation:

    Contact Information:

    Date of Consultation:

    Chief Complaint
    What is your main health concern or complaint?

    How long have you been experiencing this issue?

    Describe the nature of the complaint (e.g., pain, discomfort, sensation).

    What do you feel makes your symptoms better? (e.g., rest, warmth, cold, etc.)

    What do you feel makes your symptoms worse? (e.g., movement, stress, etc.)

    Is the problem constant or does it come and go?

    Onset and Duration


    When did the problem start? (e.g., after an accident, gradually, etc.)

    Did anything trigger or cause the issue? (e.g., stress, injury, infection, etc.)

    How often do the symptoms occur? (e.g., daily, weekly, occasionally, etc.)

    Location of Complaint
    Where exactly do you experience the symptoms? (specific body part)

    Does the pain or issue spread to other parts of the body? If yes, where?
    Sensations
    How would you describe the sensation? (e.g., sharp, dull, throbbing, burning, etc.)

    Do you feel any other sensations along with the pain or discomfort? (e.g., tingling,
    numbness, weakness, heaviness)

    Physical Modality
    Does any particular position or movement affect the symptoms? (e.g., standing, lying down,
    sitting)

    Does the problem get worse during any particular time of day or night?

    Does weather (e.g., hot, cold, rainy) affect your symptoms?

    General Physical Symptoms


    Do you experience any other health problems besides your main complaint? (e.g.,
    headaches, digestive issues, respiratory problems)

    Are you prone to feeling cold or warm in general?

    How is your appetite? Do you feel hunger at regular intervals?

    Do you have any food cravings or aversions?

    How is your thirst? (e.g., do you drink a lot of water or very little?)

    How is your sleep? Do you have trouble falling asleep, staying asleep, or waking up
    refreshed?

    Do you experience fatigue or weakness? If yes, is it worse after physical exertion?

    Mental and Emotional State


    How has your mood been recently? (e.g., anxious, irritable, sad, calm)

    Do you experience stress? If yes, what triggers it?

    How do you respond to stress? (e.g., become angry, withdraw, feel overwhelmed)

    Are you feeling mentally exhausted or drained?

    Do you tend to overthink, worry, or dwell on problems?

    How do you interact with family and friends? (e.g., social, reserved, indifferent)

    Do you experience mood swings?


    Sleep and Dreams
    Do you have any trouble falling asleep or staying asleep?

    Do you wake up feeling refreshed or tired?

    Do you remember your dreams? If yes, what type of dreams do you usually have? (e.g.,
    fearful, strange, pleasant)

    Medical History
    Do you have a history of any chronic illness or major surgery? If yes, please specify.

    Are you currently taking any medications or supplements? If yes, list them.

    Have you ever been treated for this condition before? What treatments have you tried, and
    were they effective?

    Do you have any known allergies?

    Family History
    Is there a history of any specific illnesses in your family? (e.g., diabetes, hypertension, heart
    disease, mental illness)

    Does anyone in your family have similar complaints to yours?

    Lifestyle
    How would you describe your daily routine? (e.g., active, sedentary, stressful)

    How often do you exercise or engage in physical activity?

    What is your diet like? (e.g., regular meals, healthy/unhealthy food habits)

    Do you have any habits like smoking, drinking alcohol, or any other addiction?

    Women’s Health (if applicable)


    Are your menstrual cycles regular? Any pain or discomfort during menstruation?

    Have you experienced any pregnancies or miscarriages?

    Are you currently pregnant or trying to conceive?

    Additional Information
    Is there anything else about your health or symptoms that you feel is important to mention?

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