Dept of Medicine, SKN Medical College, Pune

IPD Number : . Patient Name : . Age / Sex :

Mobile : . Weight : kg Height in meter : BMI : ..
GFR calculation by Cockroft Gault equation : Use Qx Calculate app: (Mention value here): ..

Parameter

Do You fast ?

Diet
Diet pattern : Carbohydrate
intake
Diet pattern :
Protein Intake
Diet pattern :
Fat Intake
Other Food Intake
Toothpaste / Brush /Teeth
cleaning habits
Drinking water source
Do you use water filter in
home

Choice 1

Choice 2
Yes ( How many times ): per week ..
Per month ..
{ Navratri upvas / Chaturthi / Ekadashi / any
other . }

No

Any other
Mention TOTAL fasting days in a year
.

Mention frequency of non veg diet per

week ..
Rice intake Quantity (in terms of Katori / bowl) : In Breakfast .. / In
Chapatis intake: . per day / Biscuits, bread ..per day / Any other .
Dal (Varan) intake (Katori/Bowl per day) . Chicken / Fish / Red meet qty (gms) approx. per week
Any other protein containing item with approx. qty consumed daily or weekly .
How much Oil (in Liters) is used for cooking per month for your family ? .
How many family members are there in family ? ..
Namkeen / chaat / Achaar / Hajmola / Bhel / Misal paav{(rule out fluorosis) } /Samosa / kachori / Commercial
Sweets / Burger / etc .. (Encircle the ones the patient eats at least once a week) and also mention
frequency
How many times you clean teeth daily . /
Which toothpaste /powder do you use . (Mention brand name of the paste/ powder)
Do you floss teeth daily Yes / No
(If Bore well / Well / River as source
Municipal water supply
Bore well / Well / River
then : Screen for Fluorosis)
Veg

Non Veg

Yes

No
Daily 1 or less or NO fruits or only
ocassionally
Addiction

Fruits Intake

Daily 2-3 fruits or More

Mishri (Now or in Past)

No

Yes (Mention frequency per day

. )

Tobacco (Now or in Past)

No

Yes (Mention frequency per day

. )

Do you drink Alcohol ?

No

Yes (Consider possible Vit

Thiamine B1 & B12 deficiency;
Cirrhosis ).

Did you drank alcohol in past

No

Yes

Beetle nut (Supari) / Gutkha

chewing (Now or in Past)

No

Yes (Screen for Possible Oral

submucosal fibrosis / Oral cancer
etc.)
Smoking, Smoke and related diseases

Screen For Vit C Deficiency / or

related vitamin deficiencies
(Consider possible Gastritis / GERD /
Cancer of oral cavity / esophagus /
stomach)
(Consider possible Gastritis / GERD /
Cancer of oral cavity / esophagus /
stomach)
Mention type, quantity & Frequency

Mention type, quantity & Frequency

(Mention frequency per day . )

Ask frequency and duration of
smoking

Get PFT done

Get PFT done

Do you smoke ?

No

Yes (Consider possible COPD)

Did you smoked in Past

Passive smoking exposure
from other family members or
friends or roommates ?
Chulha cooking (Present or in
Past)
Ganja / Hukkah etc. (Now or
in Past)

No

Yes

No

Yes (Consider possible COPD)

No

Yes (Consider possible COPD)

Get PFT done

No

Yes (Consider possible COPD)

Get PFT done

Zoonotic Diseases
Yes (To rule out zoonotic
diseases)

Do you have OWN any cows /

buffaloes / farm animals ?

No

Do you drink Milk ?

No

Yes

Tea? How many times daily ?

Any pets (Dog/ Cat/ Bird) in
Home ?
Mosquitoes in or around
house

Does not drink tea

Yes
Yes (Mention the pet animal in
home)

What is you present &/OR

past occupation (Screen for
Occupational hazards or risks
if any)

No
No

Yes

(To rule out zoonotic diseases)

Quantity of Milk drinking daily
.mL
Frequency per day .
(To rule out zoonotic diseases)
Rule out Mosquito borne diseases

Occupation
Present occupation ..
Past occupation (if any)
Prepared by Unit 4 : Medicine
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Is your occupation sedentary ( no physical activity / or

maximum sitting job ?)
No
Do you have excessive stress
or tension in your job ?
Do you have excessive stress
at home?Any family discord ?
Do you walk barefoot
outdoors? Do you work
barefoot in farm ?
Do you take small white tab
from GP / Pvt practioner / or
by your own regularly for
Body pain / back ache / knee
pain for months or years
together ?
Ask this Qn to relatives of the
patient : Does the patient take
the prescribed Medication(s)
regularly ?

Do you do regular Physical

exercise OR daily walking OR
play any outdoor sport
regularly ?
Have you received in past :
Influenza vaccine /
Pneumococcal vaccine /
Typhoid vaccine / Hep B
vaccine (as may be
indicated?)
Hemoglobin

Occupation
Risk factor for Obesity, Metabolic
syndrome etc.

Yes

No

Yes (Need to screen and treat

accordingly)

No

Yes

No

Yes

Describe in IPD case notes :

Evaluate for Anxiety / Depression /
panic episodes accordingly
Evaluate for Anxiety / Depression /
panic episodes accordingly

Self Medication Pattern & Compliance

Screen for eGFR

Suspect Nephropathy (NSAID) ;

Yes (Rule out NSAID & / or

steroid consumption)

No

Secondary addisons disease.

(Chronic steroid intake)

No (If No, ask and mention the

reasons for Non compliance below
Non Compliance of treatment can
Yes
)
cause treatment failure / progression

of disease etc.

Physical Activity / Exercise

If Answer Yes : then :
Name of activity/exercise/outdoor sport
Yes (Mention type of activity
.
No
and daily or weekly duration)
Daily duration in Min.
Weekly duration in minutes (If irregular exercise)
.
Vaccination Status ( Adult )

No

If Yes (Mention name of vaccine &

date of administration)
.
.

If Not, then consider to recommend

as per current guidelines of Adult
vaccination

CURRENT INVESTIGATION REPORTS OF THE PATIENT IN SKNMC IN THIS ADMISSION

FBS
PPBS
HbA1C

MCV

Vit B12 level (If done)

CXR (s/o COPD ?) : Yes / No

USG Abdo : Fatty Liver ? Yes / No

TSH

FT4

Diabetic ? : Yes / No

Hypertension ? : Yes / No

PFT report : OAD ? / Restrictive ?

Please note : Screen previous (old) Reports / Records of the patient.

Attach a Xerox copy of all previous reports and records in the IPD file.

____________________________________
Name of Doctor who interviewed the patient

______________________
Date of filling the above info

Prepared by Unit 4 : Medicine

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