Please send the details of your ailment in following format to Dr. Prashant Sawant:  

Name:                                                                

Age:

Address:

Gender:  Male / Female                    

Birth date:

Birth time:

Birth Place:

Height:

Weight:                

Occupation:

Marital status:   Married /Unmarried

Provisional / Confirmed diagnosis if any?:

Present complains with duration: 

 Family history (if significant)?:   (diabetes / hypertension / tuberculosis / skin disease etc.) 

Previous health status: (any past major illness?)

Diet:   Vegetarian / Non-vegetarian, describe.  How many times do you eat? Any irregularities in eating habit? Quantity of food in each meal (approx.)? Do you eat curd (yogurt), cold beverages and fruits at night?

Habits:   Smoking / Drinking / Tobacco chewing / other.             Specify the quantity per day.

Appetite:   Can you bare the hunger, does it subsides with less food?

Bowel habits: Frequency and nature of bowels.

Menstrual History:

Menarche (1^st menses) at age _____,

At intervals ______ days

Lasts for ________ days

Regular/irregular, Profuse/Modarate bleeding, Painful/Painless

Obstetric History:

How many children  ______, Male ____ age ______, Female_______ age

Type of delivery : Full term, Normal/ forceps, LSCS    

Investigations done:

(Blood tests, X-rays, MRI, Scan etc)

Medications:

Any other information you would like to give?