Phone: (204) 799-2962
667 Stafford st, Winnipeg, Manitoba R3M 2L9, Canada
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*Indicates Required Fields
Name
Sex
Male
Female
Occupation
Address
Age
Marital Status
Single
Partnered
Married
Divorced
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
Yes
No
Alcohol
Yes
No
Drugs
Yes
No
Patient as a person:
Appetite:
Increased
Decreased
Normal
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:
Generally Increased
Generally Decreased
Normal
Any parts specify
Offensive / Sour smell / Non Offensive
Urine:
Increased
Decreased
Normal
Pain / Smell
Type of pain / type of smell
Bowel Movements:
Normal
Constipation
Loose stools
Hard stools
Number of times per day
For Females: Menstrual history
Menstrual flow for how many days
First Menstrual Period
Last Menstrual Period
Attained Menopause:
Yes
No
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:
Submint
Dr. Kumar Belgaumkar DMS, HD
Tel: (204)284-7778
301 - 1200 Pembina Hwy, Winnipeg, Manitoba R3T 2A7, Canada
Email :
[email protected]
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Weekends: 10:00am - 1:00 pm
