PATIENT PERSONAL INFORMATION
Patient's contact number:
Assistant's contact number:
Number of children:
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?
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?