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Questionnaire

This document contains a patient information form filled out by Aiswarya Rokkam, a 32-year-old female, for her chief physician regarding her ailments. She reports numerous physical symptoms including neck, shoulder, leg, and back pain as well as stiffness, tiredness, twitching, and digestive issues. Mental symptoms include restlessness, anxiety, perfectionism, irritability, and sensitivity. She has undergone panchakarma treatment and is currently taking several Ayurvedic medications. Her medical history notes ulcers and irregular periods.

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Aiswarya Rokkam Koppu
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121 views12 pages

Questionnaire

This document contains a patient information form filled out by Aiswarya Rokkam, a 32-year-old female, for her chief physician regarding her ailments. She reports numerous physical symptoms including neck, shoulder, leg, and back pain as well as stiffness, tiredness, twitching, and digestive issues. Mental symptoms include restlessness, anxiety, perfectionism, irritability, and sensitivity. She has undergone panchakarma treatment and is currently taking several Ayurvedic medications. Her medical history notes ulcers and irregular periods.

Uploaded by

Aiswarya Rokkam Koppu
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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PLEASE FILL IN THIS FORM FOR OUR CHIEF PHYSICIAN

TO RESPOND TO YOUR AILMENT


Hospital Number, if any:
(Please mention the Reference number allotted to you from the hospital)
Name of the patient : Aiswarya Rokkam
Guardians Name
:
(In case of a minor)
Organization

Street Address

: Door No:49-54-8-2-23
Flat No:203, Vani Towers
Landmark :4th Town Police station
B.S Layout
Seethammadhara

City

: Vishakhapatnam

State

Country

India

Postal code

530013

Telephone

08897182340

Fax

E-mail ID

: [email protected]

Alternate e-mail ID

: [email protected]

Age

: 32

Sex

Female

Height

165cm

Weight

66kg

Andhra Pradesh

Structure

Medium-Obese

JOB DETAILS
PRESENT COMPLAINTS

Physical Symptoms
Neck Pain and pain in the right hand, extending till the fingers.
Pain in the shoulder area and shoulder blades on both the sides
Pain in the right leg, extending till the fingers of the feet.
Pain in the legs /Numbness after getting up from sitting or keeping them still for some
time
Stiffness and discomfort in the waist
Feeling of body always being stiff and tired, maximum when wake up in the morning,
especially palms and feet.
Sometimes pain in the knees, when stretch leg
On touching with pressure (during panchakarma massage), pain being experienced
additionally in the right jaw bone, left collar bone , both sides of the ribs, lower and
upper parts of the hands, left hip bone, outer sides of the lower part of the waist, buttock
bones on both the sides, outer and inner sides of the thighs, calf muscles, below the last
two fingers in the left feet -pains reduced after Vasti treatment.
Heavy twitching in the left eyelid, legs, hands, stomach area, and liver area.
Vigorous shaking of the index finger and slightly thumb finger in both hands - subsided
after using ayurvedic medicines.
Bloated feeling after eating food- reduced after Vasti treatment
Acidity - squeezing type of pain in stomach and sometimes acid reflux.
Gums becoming smaller and frequent infections and pain in the gums.
Have dry, tired feeling in the eyes when wake up in the morning .
Dry hair and hair loss with fungal infection and dry skin
Thumb nail in feet got broken and peeled off two to three times.
Have frequent colds- runny nose with watery discharge, slight headache and heavy
sneezing -dust allergy
Irregular periods, heavy bloating in the breasts before periods. Severe pain in the back and
sometimes in right leg and painful bowel movements during periods.
Very low libido
Disturbed sleep - sometimes difficulty in falling asleep and sometimes wake up by little
noise in the middle of the night.
Giddiness feeling once in a while - subsided after using medicines.
Dry feeling in the mouth ( no feeling of metallic taste).
No pain in the joints - no signs of swelling or redness and feverish feeling.
Mental Symptoms

Restlessness and hyperactive (mind always with racing thoughts -unable to relax, do
things fast and move fast)
Anxious by nature.
Too worried about what others think.- lack self confidence- depend on others opinionsensitive by nature.
Excessive talking
Aim for perfection or give up completely- no intermediate level.
Irritable
Critical

Full History of present complaints:


Details of investigations done so far:

Details of treatments done:

Underwent Panchakarma treatment for 21 days from 20th Dec 15 to 12th Jan 16 at home
-including Udwarthanam, Podikhizhi, Naragana khizi, Elakhizhi, Kati Vasti, Greeva
Vasti,Bandage and 3 Kashaya vasti and 5 Sneha vasti
Consulted Dr Rajeesh, Kottakal Arya Vaidya Sala, Visakhapatnam (07382552255)

Current Medication:

Rasnasapta kam kashayam 10 ml


Prasaranyadi Kashayam 10 ml
Yogaraja Guggulu vattika
Vatagajankusa Rasam
Dhanvantaram Tailam
Pinda Tailam

Allergies

History of previous illnesses: (Option)

Past Medical History


DISEASES

YES

NO

MALARIA

No

DIABETES

No

FILERIA

No

JAUNDICE

No

PILES

No

FISTULA

No

ULCER

Yes

ANEAMIC

No

OTHERS

YES / NO
Inpatient Treatment Required

Yes

STATE OF DIGESTION

Normal / Less / More


APPETITE

Normal
Regular / Irregular

BOWEL HABITS
URINE
QUANTITY

SLEEP

Irregular
Adequate / Less / More

Adequate
Adequate / Less / More / Disturbed
Disturbed

MENSTRUATION
Regular / Irregular

CYCLE

Irregular
Normal / Less / More

FLOW

More
Pain / Clots / Muscle cramps

ASSOCIATED
WITH

Pain / Clots
Married / Unmarried

MARITAL STATUS

Married

Delivery: Problems if any

DIETARY HABITS

Vegetarian / Non Vegetarian


Non Vegetarian

SCHEDULE

MENU

TIMINGS

EARLY MORNING

Lemon juice

7:30AM

BREAK FAST

Idilli/dosa/upma

9:00AM

MID MORNING

Milk

11:00AM

LUNCH

Rice, vegetable, non-veg, dhal

1:30PM

EVENING

Fruits, biscuits, snacks

5:30PM

NIGHT

Rice, vegetable, non-veg, dhal

8:00PM

ADDICIONS
IF ANY

Others please specify:

Smoking / Alcohol / Tobacco chewing

No

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