For
Office use
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.
___________________________________________ |
|||
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.