The two most common types of diabetes mellitus used to be categorized as These two forms of diabetes were also referred to as insulin dependent and non …
Note: To save this document click on File-Save As and give the filename to
save
Care n Cure Health Clinic
269, 1st Floor, 2nd Cross, 3rd Main, Cambridge Layout,
Shirdi Sai Baba Mandir, Road, Ulsoor, Bangalore, Karnataka,
India-560008
Phone : 91-80-25561088
Email: josyjoya@indiatimescom
Please fill in this case sheet to help us treat you better
Email or snail mail this case sheet to us to the addresses
given above
CASE SHEET FOR OBESITY
PERSONAL DETAILS
Name : _______________________________________________
Age : ______
Sex : ______
Occupation : __________________________________________
Address : _____________________________________________
_____________________________________________________
_____________________________________________________
Tel No : ______________________________________________
E-mail ID: ____________________________________________
PRESENTING COMPLAINTS
1 Since when did the complaint start?
2 Is anybody in your family obese other than you?
3 Do you have the habit of eating snacks?
4 Are you a vegetarian or non-vegetarian?
5 What is your present weight and height?
6 Which are the main areas that you are gaining weight?
7 Which shampoo and oil are you using presently?
8 Do you have any other health related complaints like Thyroid
problems, Diabetes, Hyper Tension, etc?
Associated Complaints - Any gastric complaints, dust allergy, any
headache you get when exposed to sunlight or any other health wise
problems you are suffering along with the above complaints?
HISTORY
1 Did you have any illnesses in childhood like Jaundice, Typhoid,
Chicken Pox, Malaria, Pneumonia, etc?
FAMILY HISTORY
1 Does anybody from your family members including your parents
and grand parents have /had any health related problems like
High/Low Blood Pressure, Diabetes, Arthritis, skin complaints,
asthma, pneumonia, tuberculosis, cancer etc?
TREATMENT HISTORY
1 Have you undergone
treatment for serious illness in the past?
- like Asthma, Dysentery, Tuberculosis, Typhoid, Diabetes,
Malaria, Hypertension or some problems of the skin such as
Eczema, Psoriasis, Ring-worm, Urticaria, Measles, Mumps,
Herpes, Chicken-pox etc,
2 Have you undergone any surgeries/operations/Injuries in the
past?
GENERAL HISTORY
1 How is your food intake? Veg or non veg?
2 Do you skip food?
3 How many glasses of water do you drink every day? Do you
prefer hot water/cold water/normal water?
4 How is your sleep do you cover yourself with bed sheets?
How? legs only or entire body Do you feel fresh on waking
up? The position you prefer to sleep in? eg on back, on
stomach etc
5 Do you have any urinary complaints or infection?
6 Do you sweat very much? If yes, which are the areas of your
body that sweat more? Any offensive smell?
7 Do any of your body parts feel more hot/cold? If yes, which
are the areas?
8 Which climates do
you like most?
9 Do you have any addictions like smoking, drinking, coffee,
tea etc?
10 Are you suffering/suffered from constipation or hardness of
motion?
11 Do you like to put fan ?if so in what speed full speed or
medium speed or do you avoid putting fan in full speed due
to some health problems or discomfort?
12 Any addictions like smoking, drinking alcohol, chewing
tobacco, pan masala if so since how long?
13 Any peculiar habit of washing hands several times or checking
the door at night etc?
Which climate you like most summer winter medium why you like that
climate
Do you like sweets, salty, spicy, ice cream, juice, milk[plain
milk] or flavoured milk as per your real nature or whether you
avoid those things because of any particular reason? Any like or
dislikes or avoid for the above
do you like plain milk without any flavour if you are offered?
please clearly mention whether you like or dislike or
disagree or avoid the following
Bitter Salt Extra
Sweet
Sour Bread
Butter Fats plain Milk
Fish Chalk
Eggs Spicy Food Meat Fruits
Cabbages
Onions Warm food- Drink Cold Food-Drink Anything Else:
MENSTRUAL HISTORY ONLY FOR FEMALES
1 What was the age when you got your first menses?
2 Is your period regular?
3 How many days do your period last?
4 Is there any clots or whitish discharges?
5 Are there any other associated complaints associated with
periods like backache, headache, etc?
OBSTETRIC HISTORY ONLY FOR FEMALES
1 How many children do you have?
2 Did you have a normal or caesarian delivery?
3 Any abortions/miscarriage/forceps deliveries?
BRIEF PERSONALITY PROFILE
About your mental state and your emotional nature Please answer in
this part about your situation in life and about all the things that
are bothering you Kindly be frank and open
How do you describe yourself as a person? Min 200 words please
Are you
punctual by nature do you keep time schedule do you complete
work in time without pending?
Do you try to finish the work in time or keeps postponing?
How is your confidence level?
How good your studies average or above average? How good you are/were
in mathematics?
Are you particular about cleanliness and neatness?
Are you anxious about which matters?
Are you reserved or extrovert by nature do you make friends fast or
selective friends?
Any stage fear or exam fear initially or throughout?
Are you fearful of anything such as Animals People Being Alone
Darkness Death Disease Robbers Sudden Noise Thunder Of the
Future Of something unknown
High places Timidity or any other Are you doubtful or suspicious? of
what?
Unpleasant experiences Disagreements, Humiliation; Fights; Deaths;
Separations; Divorce, Monetary Loss in business or losing a job, love
affair failure etc
If you are scared of any animals, insect, darkness height, water,
robbers etc mention of childhood fears too
What are you jealous about? of whom ? , From what symptoms do you
suffer when jealous?
In which matters are you impatient? Hurried?
How long do you remember hurts came to you by others? Offended easily?
How much revengeful are you?
What are you proud of?
Does your pride get easily hurt? Egotism
Depressed/Brooding etc?
Do you ever become suicidal ? Yes No
When?
If so in what manner do you contemplate to end your life?
Even then are you afraid of dying ? Yes
When are you cheerful?
Any unwanted thoughts any time? What are they?
Have you any imaginary sensations or fears?
Do you hear voices as that you are called or anything else in this
line keeps on occurring in your mind unduly? Yes No
How is your memory?
For what is poor? eg names, places, faces, what you have read, etc
Do you weep easily Yes No
What makes you weep?
How do you feel after weeping?
How do you feel if someone offers sympathy and consolation?
Are you easily irritated? Yes No
What makes you angry?
What bodily symptoms do you develop when angry ? , eg trembling,
sweating etc
Do you like company ? or like to remain
alone ?
How seriously are you affected by disorder and uncleanness in your
surroundings ? Yes No
What are the greatest griefs that you have gone through in your life?
What are the greatest joys that you have had in life?
What activities you deeply like?
Are there any matters which you deeply dislike?
In your opinion, which aspects of mind and moods are not agreeable to
you In spite of your awareness and maturity, are unable to change
this aspect?
Give a clear cut picture of your situation in life and your
relationship with each of your family members, friends and associates
in work
How does the future look to you?
Are you transparent/open minded by nature? Or are you a closed
person?
Source:e-mbainc.com
