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Patient Registration Form



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*Name:

*Address:
*Age:
*Sex: *Occupation:
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Fax:
*Email:
Symptoms:
Tremors
Slow Movement:
 Rigidity Stiffness:
 
Micrographia:
Speech Difficulty:
 
Reduced swings:
Gait Problem:
 
Short stepped:
 Shuffling Leg:
 
Difficulty in
Getting Up:
Joint Pain:
 
Postural Instability:
   
Blinking Eyes:
Dryness:  Itching:
Hard to
Swallow Food:
Sleep Disorders
Difficulty in Sleep:
Pain during Sleep:
 
Nightime
Urination:
Nightmares:
 
Rapid or
Pounding Heart:
Dryness of Skin:
Problems with Memory
Confusion:
Mood Changes:
 
Depression:
Sadness:
 
Nausea:
Heartburn:
Loss of Appetite
Constipation:
Dry Mouth:
 
Sexual Dysfunction:
History including medical and surgical:

Present Complaints:

Symptoms, Duration and Previous Diagnosis:
Addictions:
Alcohol:
Smoking:
Tobacco:
Drugs:
Other Habits:
Non Vegeterian:
Vegeterian:

Family History and Other Investigations:

Diabetes, Hypertension - CNS findings in brief (Muscle Tone, Power, Reflexes, Involuntary Movement):

Difficulty in achieving and maintaining an erection?
Prostate:
Thyroid:
 
Fatigue:
Weight loss:
Current Medications:

Comments:


         
   
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