PATIENT'S NAME
*
ADDRESS
*
Age
*
Years
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
47
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
Sex
Male
Female
Weight
Kg
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
47
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
Date Of Birth
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
1890
1891
1892
1893
1894
1895
1896
1897
1898
1899
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
Year
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Height
Feet
1
2
3
4
5
6
7
8
9
10
Inch
1
2
3
4
5
6
7
8
9
10
11
Education
(Select one)
High School Grad
Voc/Tech School
Some College
College Grad
Some Post Grad
Post Grad Degree
Under Grad Diploma
P.G. Diploma
Certificate
Other
Family History
Whether born to parents marrying near cousins
Yes
No
Any significant developments
at the time of Birth
Disease development
Age when the first symptom detected
By Birth
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
47
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
Age when any diagnosis made
By Birth
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
47
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
How symptoms progressed
Tests so far done
Biopsy
E.M.G.
C.P.K.
Biopsy+E.M.G.+C.P.K.
Biopsy+E.M.G
E.M.G.+C.P.K.
Biopsy+C.P.K.
Others
A. Physical Details
Walk unaided
Yes
No
Walk aided
Yes
No
Stand Unaided
Yes
No
Standaided
Yes
No
Raise my arms
Yes
No
Move my arms
Yes
No
Move my legs
Yes
No
Straighten my legs
Yes
No
Lie on my stomach
Yes
No
Lie on my back with supportive pillows
Yes
No
Lie on my back without supportive pillows
Yes
No
Sit myself up
Yes
No
Sit up unsupported
Yes
No
Sit up with support of pillows/wedges
Yes
No
Turn myself in bed
Yes
No
Lift up my head when lying down
Yes
No
Dress myself unaided
Yes
No
Dress myself aided
Yes
No
Get in and out of bed myself
Yes
No
Get up and down from a chair myself
Yes
No
I am unable to call for assistance and require a buzzer to hand
Yes
No
B. Feeding
Feed myself unaided
Yes
No
Feed myself using aids
Yes
No
Cut up my food
Yes
No
Eat lying down
Yes
No
Take drinks from my side lockers
Yes
No
Hold a up unaided
Yes
No
Drink from an ordinary cup
Yes
No
Drink through a straw
Yes
No
C. Toilet
Sit on a toilet unaided
Yes
No
Wipe myself
Yes
No
Get up from toilet unaided
Yes
No
Get up from toilet aided
Yes
No
Use a bed pan/bottle unaided
Yes
No
Use a bed pan/bottle aided
Yes
No
Wash myself
Yes
No
Wash my hands and face only
Yes
No
Comb my hair
Yes
No
Clean my teeth
Yes
No
Blow my nose
Yes
No
Shave myself
Yes
No
D. Medication
Swallow tablets
Yes
No
Take liquid medicine
Yes
No
E. Additional Information
Design & Development : Focus Universe, Solan, Himachal Pradesh
Ph. (91)1792-221122, 09318806308, 09218630007
