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Thursday, May 23, 2013
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Col.H.P.Singh, Age:87, was out and out a disciplinarian, defense personnel who fought in World War II and defended Indian boundaries in 1962 during Chinese Aggression is an Alzheimer’s patient ...
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History Taking Performa
Name
Date of Birth
Sex
Male
Female
Height
Weight
Please provide following information
Occupation
Email
Marital Status
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Divorced
Chief Complaint with duration
Mode of Onset
Sudden / Gradual ?
Sudden
Gradual
How did the problem start?
How has it progressed?
Past history- pl. specify the details of the following (if any)
Hospitalization?
Surgery?
Accident?
Family history/Personal history of any of the following?
Diabetes?
Hypertension/High blood pressure
T.B?
Memory loss
Any Other ?
Any other medication that the patient has been taking ?
Diagnosis details-
By which doctor?
Name of the hospital?
Place?
Date of diagnosis?
If possible, attach a copy of your medical reports viz. Blood Report, X- Ray, CT Scan, MRI, etc.
Life style of the patient before onset of ailment ?
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