PATIENT PERSONAL INFORMATION

Patient's name:


Age:

Address:

Occupation:

Patient's contact number:


Assistant's name:


Assistant's contact number:


Number of children:


Patient's condition:


Weight:

Duration of ailment:


Number of stroke occurence:


Side of body affected:


Ever had surgery? Explain:


Ever had treatment anywhere? Explain:


Are there any changes?


What happened after last treatment:


How much payment done?


Can eat or drink?


Can speak?


Vocal condition:


Droopy mouth? Which side?


 How many times defecating in a day?


How many times urinating in a day?


Hypertension - Yes or No - How Long?


Diabetes - Yes or No - How Long?


Heart Problems - Yes or No - How Long?


Haemodialysis - Yes or No - How Long?

Note: