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PROFORMA

The document is a proforma for medical assessment, detailing patient history, symptoms, past medical history, personal history, present medication, physical examination findings, investigations, and diagnosis. It includes sections for various symptoms related to osmotic, constitutional, cardiovascular, thyroid, and other health issues. The proforma is structured to gather comprehensive information for diagnosing conditions such as diabetes mellitus, hypertension, and thyroid disorders.

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Venkitesh M.G
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4 views5 pages

PROFORMA

The document is a proforma for medical assessment, detailing patient history, symptoms, past medical history, personal history, present medication, physical examination findings, investigations, and diagnosis. It includes sections for various symptoms related to osmotic, constitutional, cardiovascular, thyroid, and other health issues. The proforma is structured to gather comprehensive information for diagnosing conditions such as diabetes mellitus, hypertension, and thyroid disorders.

Uploaded by

Venkitesh M.G
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

PROFORMA

Guide: Dr. MILIND V BOTRE Studied by: Dr. VENKITESH M G

NAME: TEL:
AGE: DOA:

SEX: IP NO.
ADRESS:

HISTORY OF PRESENTING COMPLAIN:

OSMOTIC SYMPTOMS: YES NO DURATION

INCREASED THIRST:
INCREASED URINATION:
INCREASED FOOD INTAKE:

CONSTITUTIONAL SYMPTOMS: YES NO DURATION

DELAYED WOUND HEALING:

RECURRENT SKIN INFECTION:

CARDIOVASCULAR SYMPTOMS: YES NO DURATION

CHEST PAIN:
BREATHLESS NESS:
COUGH:

EDEMA:
PALPITATION:

Page 1 of 5
OTHERS SYMPTOMS: YES NO DURATION

IMPAIRED HEARING:

BLURRING OF VISSION:

THROID SYMPTOMS: YES NO DURATION

LOSS OF WEIGHT:
LOSS OF APETITE:

TREMOR:
MENESTURAL
DISTURBANCE;

EYE PROPTOSIS:
WEIGHT GAIN:

ANXIETY:
COLD INTOLERANCE:

HOT INTOLERANCE:
INCREASE APETITE:

ECCESS
SWEATING OF HANDS:

GAIN WEIGHT:
LAZINESS:
DIARREHA:

CONSTIPATION:
DRY SKIN:

VOICE CHANGE:
HAIR LOSS:

TIREDNESS:

Page 2 of 5
WEAKNESS:
FATIGUE:

LETHRGY:

PAST MEDICAL HISTORY: DURATION

DM:
HYPOTHYROIDISM:

HYPERTHYROIDISM:
HTN:

IHD:
RETINOPATHY:

NEPHROPATHY:
STROKE:

NEUROPATHY:
SENSORY DISTURBANCE:

(TINGLING, PAIN, NUMBNESS)


MOTOR DYSFUNCTION:

URINARY RETENTION:
DYSPEPSIA:

ABDOMINAL PAIN:

PERSONAL HISTORY: YES NO DURATION

SMOKER:

ALCOHOL:
SLEEP:

DIET:

Page 3 of 5
PRESENT MEDICATION: DURATION

INSULIN:

ANTI HTN:
LIPID LOWERING AGENT:

ANTI THYROID DRUG:


ORL ANTI DIABETES DRUGS:

GENERAL PHYSICAL EXAMINATION:

PULSE:
BP SPINE:

BP STANDING:
BMI:

WAIST/HIP:

CNS:

SENSORY: TOUCH:
PAIN:

TEMP:
VIBRATION SENSE:
JOINT POSITION:

CVS:

RS:

ABDOMEN:

Page 4 of 5
INVESTIGATIONS:

HB: CREATININE:

TC: BLOOD UREA:


DC: LIPID PROFILE:

ESR:
HBA1C:

FBS:
PPBS: URINE ROUTINE:

T3:
T4:
TSH:

ECG:
ECHO:

FUNDUS EXAMINATION:

DIAGNOSIS: DURATION:

DM:

IHD:
HTN:
NEPHROPATHY:

RETINOPATHY:
OBESITY:

NEUROPATHY:
HYPERTHYROIDISM:

HYPOTHROIDISM:

Page 5 of 5

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