Case Submission Form(Chronic)

Describe all your present complaints, first the most troublesome ones, then others. As far as possible, try to provide the following details about each complaint with date of its start, if possible:

i. Nature of the complaint

ii. Seat of the complaint

iii. Conditions and circumstances which cause increase, decrease or relief of the complaint

iv. At what time of the day or night is the complaint worse?

v. Any cause for this particular complaint?

  1. What do you think is the cause of your present complaints? (e.g. shock, fear, worry, stress, dietary errors, unhealthy living, overexertion (mental and/or physical), injury, exposure to cold, heat, wetting, etc.)
  1. What medicines have been taken so far and with what result? If you do not remember all, just name the last one.
  1. How do changes in temperature, of weather and season affect you? ( warm, cold, winter, summer, extreme heat or cold, wet, etc)
  1. What tests have been done so far? Give a summary of their findings.
  1. Personal History:

a: mode of living, habits, activities, social and domestic relations, any accident or event which you think may have something to do with your present troubles.   

b: any difficulty or problem in discharging your day-to-day domestic or occupational obligations?

c: any irregularity in daily routine life e.g. meals, rest, sleep, etc? 

d: any addiction?

e: colour, height, weight. Howmany pounds (or kilos) have you lost or gained since the beginning of the present illness?

f: anything else?

  1. Miscellaneous:

i) Tell about your thirst (how much and how often you drink) and appetite (voracious, normal, wanting, easy satiety, cannot bear hunger, etc.);

Any problem after eating or drinking? 

ii) Name the items you like the most (sweety, salty, spicy, sour, coffea, tea, cold drinks, fats, fruits, milk, meat, tea, vegetables, ice etc.);

iii) Could your liking for a certain thing be called a craving (i.e. a very impassioned desire – (its equivalent in Urdu is shadeed khahish – nehari  mujhay diwangi ki had tak pasand hai! Children crave toffees, ice creams); 

iv) Name the food items you dislike and, if possible, also give reasons why you dislike them.  Is your disliking for a certain food item so intense as to be termed an aversion? (In Urdu it can be: sakht napasand, chir, nafrat);

v) Condition of tongue (e.g. coated, clean, dirty etc.)

vi) Condition of nails (any cracks, spots etc.)

vii) Any warts, moles or growths? Where?

viii) Stool, urine, sweat: Any thing remarkable ?

ix) Sleep and dreams: Any thing remarkable?

  1. Past History:

a: Describe all or as many episodes as you can remember of the skin diseases you have had since birth with their treatment and results. Also mention dates if possible;

b: Any kind of venereal disease with treatment and results;

c: Vaccination/inoculation, etc., since birth. Any ill-effects after any of them?

d: What illnesses have you had since birth? If possible, describe in chronological order. I am particularly interested in knowing about mumps, measles, pox, whooping cough, throat troubles, pneumonia, malaria, typhoid, etc.

  1. Family History:

Presence of any of the following diseases in your blood relations (both paternal and maternal):  asthma, biliary colic, cancer, diabetes, epilepsy, fistula, high blood pressure, insanity, peptic ulcer, piles, renal colic, rheumatism, tuberculosis, etc.