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Rheumatology Form

* Name

* Age

Sex

* Address

* Contact No

Occupation

Complaint

How It Started

Duration of Complaint

No of Joints

Pain Swelling Redness

Early Morning Stifness if Yes morning Stifness upto

Mins/Hours

Are You Suffering from any Diseases below

Hypertension

Chronic Back Pain

Diabetes Mellitus

Cancer

CHD

Stroke

Peptic Disease

Alcohol

Renal Disease

Smoking

Chronic Disease

Allergies/Adverse Events

Thyroid Disease

Joint Surgery

Skin,Eye Neurological Problems Environment

Head Ache

Hair Fall

Mouth Ulcers (Mucosal Ulcers)

Any Prycological Problems

 

If Married any History of Abortions

 

Any History of Fits [Seizure]

 

Weight Loss or Gain

Any other Symptoms/Complaints do you want to explain

Any of your family member Suffering/Suffered with similar problems

Any Laboratory/Radiological tests done
If Yes give the details

Meditation Taking
If Yes give particulars of Meditation

How it is Helping

Are you able to do daily activities without help
Any Other

 
 
 
 
  Advance Rheumatology Clinic
1st Floor, Kautilya Building
6-3-652
Medinova Compound
Somajiguda
Hyderabad 500082
Tel: +91-40-23307432
Cell: 9247435254
AP, INDIA
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