For Office use    

                                                                                  Lab. Ref. No.______________                                                                       Date: ______________    

Particulars of the patient:

Name ______________________________________________________   Age _______ Sex ________ 

Address_____________________________________________________________________Wt._______

O.P.D. No. ______________________________________________________     MRD No. ___________________  

 

1.  Fever   

Frequency______________________________________  

Day / Night / Evening with chills / rigors  
2. No. of  attacks of lymphangitis/ lymphadentis in the past year if any No. ___________________________________________ Central/ Axillary / Inguinal / Generalised  

3. Pain & swelling in the limb affected 

   Rt. / Lt.         

Arm

Leg  

 

Wrist

Ankle

Hand  

Foot

Duration

Weeks ...........

Months ...........

4. Pain in joints ( One joint / joints)

Pain    

Yes/No 

Affected 

Rt. Side

Lt. side

Limbs

Upper

Lower

Duration

Weeks ...........

Months ...........

 

5. Abdomen  

Pain    

Yes/No 

Location 

Central or not    

Duration

Weeks ...........

Months ..........

.
6.  Hydrocele/Epididymoorchitis/      Funiculitis/Elephentiasis/        Lymphoedema Breast /Female Genitalia

Progress

Size

Stable     

Increasing

Affected  Rt. sided  

Lt. sided     Bilateral  

Duration  

Months _______        

Years _________      

                                                                

7. Urine appearance    

Normal/ Milky/

Red  

8. Presence of filariasis                         

   within the family members  

 

Yes/ No

9. Comment of the physician who  has 

   seen you earlier in this regard  

   (including any kind of investigation

   such as DLC, ESR, Urine 

   albumin/Sugar and treatment taken)  

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

               

   

 

10.  Persistant cough                                        Dry / Associated with expectoration  

11.  Fever                                                        Regular  / Intermittent  

12.  Breathlessness / wheezing                           Yes / No  

13.  Any other information on clinical condition      _____________________________________        

      such as TPE, EMF, CSR, Tenosynovitis,         ________________________________________

      Glomerulonephropathy, Acute conjunctivitis,  ________________________________________

      Iridocylitis etc.

 

 

 

BACK