Dr. Kumar Belgaumkar DMS, HD
Tel: (204)284-7778
Email :[email protected]

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*Indicates Required Fields
Name:*
Sex:*
Occupation:
Address:*
Age:*
Marital Status:*
Email:*
Health Concern(s):
In the order of appearance

History of present condition(s):
Explain in detail how and when the condition(s) started, progressed and the present state.

Personal History:

Past History:
Any diseases which occurred in the past like tuberculosis, hepatitis, typhoid, arthritis, blood pressure, diabetes, HIV, cancer etc., may be described in detail in sequential order. Also specify any other diseases from childhood down to the present, chronologically with its nature, duration, severity, type of treatment undergone etc. in as much detail as possible.

Have you undergone any surgical procedures? If so, for what and when?

Prescription Drugs:
List the medication(s) and the dose(s) you are taking and the reason(s) as to why.

Supplement / Vitamins and Non prescription drugs:
List all the supplements, Vitamins and Non prescription drugs you are taking with the amounts.

Family History:
Please list any relevant diseases in your immediate family. Examples: Blood pressure, Diabetes, Hepatitis, Tuberculosis, Cancer, HIV Infection, Tumors, Arthritis, Skin diseases etc.

Personal History:
Specify life situation
(Mile stones and other developmental details in children)

Tobacco
Alcohol
Drugs
Patient as a person:

Appetite:
Thirst:
What kind(s) of food do you crave? Examples: Sweets / Salty / Sour / Spicy
What food(s) do you have an aversion to? Any food or environmental allergies?
Perspiration:
Any parts specify
Offensive / Sour smell / Non Offensive
Urine:
Pain / Smell
Type of pain / type of smell
Bowel Movements:
Number of times per day
For Females: Menstrual history

Menstrual flow for how many days
First Menstrual Period
Last Menstrual Period
Attained Menopause:
Complaint associated with periods:
Sexual History:
Please specify any problems or concerns.

Sleep:
Nature, duration, position, dreams, snoring etc

Mind:
Patient's reactions towards society, stress, family and friends.

Any other details: