Patient Registration Form

 
Name:   PEFR:  
Occupation:   Tel No.:  
Address:    
Age: Sex:
Height: Weight(KG):
B.P.: Sugar:
 
1. How DID YOU COME TO KNOW ABOUT SWASA CLINIC?
           
2. Do You (Patient) have repeated attacks of Cough & Cold, Sneezing, Difficulty in Breathing, Whistling sounds in throat or chest?
   
3. Do you have itching of eyes, nose, ears or throat or skin any time?
   
4. Is your above problems disturbing your sleep any time?
   
5. Is your problems disturbing your work or profession or job?
   
6. Do you worry about your future beacuse of these problems?
   
7. Is it disturbing your mental peace, social life and family life?
   
8. Is anybody suffering with same problem in your family or blood relatives?
   
9. You visited many doctors, used many drugs but you are not satisfied, Is it so?
   
10. Do you worry about- growth, studies, games, carrier, marriage, future, cost of tratment and side effects of drugs?
   
11. Are you suffering since long time with this problem?
   
12. Is your problem triggered by exposure to dust, weather changes, cool items, smoking or scents or perfumes or powders?
   
13. What you tried till now for your problems?
   
         
             
14. You have any other problem?
     
             
                     
Other Problems  what you have?              
     
 
PFT Report (SPIROMETRY) :
Blood Report (*CBP, *ESR, *AEC) :
Blood Report (SERUM IGE, BLOOD SUGAR, BLOOD UREA) :
Other Report (*CHEST X-RAY, *SPUTUM FOR AFB, HRCT-CHEST) :
Other Report (ECG, 2D ECHO) :
 
 
Describe here exactly what you want from the Doctor  about your health problems : 
 
 
I have read the Terms And Conditions and agree to the same.
 
 
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