Case History Form
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Case No:
*
Venue:
*
Date:
*
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Name
*
Age:
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Sex
*
Male
Female
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Address:
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Height
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Weight:
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Contact Number:
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Email ID:
Operation
*
Previous Illness/Disease If Any:
Present Illness/Disease If Any:
FAMILY HISTORY
H/O Cancer/TB/Diabetes?
*
Yes
No
If yes, who?
*
Habits
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1. H/O Smoking? (Cigarette/Bidis/Hookahs)
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Yes
No
How Often Daily?
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29'
30
Since how many years??
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29'
30
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2. H/O Consumption Of? (Betel-leaf/ Betal-nut/ Tobacco)
Yes
No
How Often Daily?
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29'
30
Since how many years??
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29'
30
2. H/O Consumption Of Alcohol?
Yes
No
How Often Daily?
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2
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8
9
10
11
12
13
14
15
16
17
18
19
20
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25
26
27
28
29'
30
Since how many years??
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29'
30
Any other addictions / habits?
OCCUPATION
Occupation
*
Sedentary
Physical
Involvement / Use Of Hazardous Chemical
Polluted Area
HISTORY FOR MAMMOGRAPHY
1. Are you still having menstrual periods?
*
Yes
No
If yes then LMP:
*
If no then a)Onset of Menses
*
If no then b)Age Of Menopause
*
Field #29 (copy)
2. H/O Breast Feeding:
Yes
No
For how Long?
How many children?
1
2
3
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9
10
3. Present Complaints:
a. Lump in Breast
*
Yes
No
b. Change in size
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Yes
No
c. Discharge through nipples
*
Yes
No
d. Puckering/Dimpling of skin over breast
*
Yes
No
e. Constant Pain
*
Yes
No
f. Loss of weight / Loss of appetite
*
Yes
No
g. Change in bowel habits
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Yes
No
h. Persistent constipation
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Yes
No
i. Any urinary complaints
*
Yes
No
I hereby give consent for complete examination & screening for cancer detection upon me. I have been informed & am aware that not all cancers can be detected by screening. I have been also explained that screening camps is applicable for common detectable cancers on it. It is also explained that my report is applicablt to my present conditions only. I shall not hold GKCT/Anil Cancer Clinic/Staff/Volunteers responsible for any future reports/cancer reported through other tests/future camps.
*
I agree
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