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PCAAC Patient Full History and Examination Form - Dr. Sunita Shukla
Praana Charitable Allergy Asthma Clinic (PCAAC) -- Dr. Sunita Shukla, Mumbai, Maharashtra, India
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* Indicates required question
Date and Time of Appointment
*
MM
/
DD
/
YYYY
Time
:
AM
PM
This form is being completed by:
*
Your answer
Patient ID
*
Your answer
Patient's Full Name
*
First name Middle initial Last name. Example: Pudupakkam K. Vedanthan
Your answer
Patient's Sex
*
Male
Female
Patient's Date of Birth
*
MM
/
DD
/
YYYY
Patient's Occupation
*
Your answer
Type of Appointment
*
Initial Visit/Consultation
Follow-up Visit/Consultation
Patient's Chief Complaints:
*
Your answer
Present Problems: EENT
*
Doctor: Please describe the following: 1. Date of onset; 2. Progress; 3. Seasonality; 4. Precipitants; and 5. Treatment plan.
Your answer
Present Problems: CHEST - Part 1
*
Select all that apply.
Cough
Wheeze
Sputum
Blood in the Sputum
Shortness of Breath
Nocturnal Symptoms
Other:
Required
Present Problems: CHEST - Part 2
*
Doctor: Please describe the following: 1. Date of onset; 2. Progress; 3. Seasonality; 4. Precipitants; and 5. Treatment plan.
Your answer
Present Problems: GI (Acid Reflux)
*
Doctor: Please describe the following: 1. Date of onset; 2. Progress; 3. Seasonality; 4. Precipitants; and 5. Treatment plan.
Your answer
Present Problems: SKIN (Rashes)
*
Doctor: Please describe the following: 1. Date of onset; 2. Progress; 3. Seasonality; 4. Precipitants; and 5. Treatment plan.
Your answer
Current Treatment & Medications
*
Your answer
Any other allergies? (Foods, drugs, insects)
*
Your answer
Family History
*
Positive
Negative
Unknown
Other:
Personal History: SMOKING
*
Frequent Smoker
Occasional Smoker
Second-hand Smoker
Non-Smoker
Other:
Personal History: ALCOHOL
*
Frequent Drinker of alcohol (4+ drinks per week)
Occasional Drinker of alcohol (less than 4 drinks per week)
Non-Drinker of alcohol (zero drinks per week)
Other:
Personal History: ENVIRONMENTAL
*
Select all that apply.
Rural
Urban
Animals
Biomass Fuel
Cigarette Smoke
Other:
Required
PE: SKIN
*
Your answer
PE: ENT
*
Your answer
PE: LUNG
*
Your answer
Add any additional comments below.
Your answer
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