Navodhaya Siddha Hospital & Research Centre
 
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NAVODHAYA® SIDDHA HOSPITAL & RESEARCH CENTRE
No.20 New No.35, Arcot Road,
Kodambakkam (also at valsarwakkam),
Chennai - 600 024.
Phone: 91 44 24810752 / 24727396
Mobile: 91 9444010752, 9444027396
E-mail: navodhaya2006@yahoo.co.in

Consultation Procedure:
     
  1) Case history & Clinical reports
    Send complete case history of patient in given feedback form below and
latest scanned clinical test results and radiological results must be furnished through email or by post
  2) Consultation Fee.
   

Within India Rs.300/-
FOREIGN: Rs.600/-(or US$ equal to it)

CURRENT A/C 5007- THE CATHOLIC SYRIAN BANK,
CHENNAI 600024.
S.INDIA

IN CASE OF D.D-in favour of
“NAVODHAYA SIDDHA HOSPITAL & RESEARCH CENTRE”
CHENNAI-600024
  3) Now you can call the hospital for appointment(9 a.m to 6 p.m)
    Procedure: Consultation through teleconference or in person as
preferred. you can talk to the doctor in English, Tamil, Hindi, Telugu &
Malayalam

Date

Age
Sex Male Female
Name
Address
Phone
Occupation
Marital Status
Children
Diabetic Yes No
H.BP/L.BP/High Cholesterol H.BP L.BP High Cholesterol
Patient in a Mobile Condition Yes No
Present Health Problems. Don’t Write one word, Give full details.
Nature of Work Office Out Door Roaming
Late Night work Yes No
Any Allergy/Wheezing/Sulpha Allergy Wheezing Sulpha
Gastric Ulcer/Stomach Pain Gastric Ulcer Stomach Pain
Any Heart Disease/Attack Any Heart Disease Attack
Asthma Yes No
Daily Loose Motion 2 3 4
Kidney Disease Yes No
Any Deformity? Walking with a tilt or support?    Tilt Support
 I. CONDITION OF MOTION AND URINE :
Motion
Daily Once Twice (Morn and Night)
Many times (3-4-5)
After Meals Tight Once in 2-3 days
Nature Painful & Hard Semi Solid
Watery
Loose Motion – Frequent Diarrhoea
Constipation Occational On Laxative (daily / often)
After spicy food After N.V.meals
Motion with Piles – Mass growth in Anus (1-2 or more) Fistula
Blood Discharge Mucus in motion
Worms in motion Arial Fissure
Urine
Colour Clear Dark Yellow Pale Yellow
Turbid Oily Sedimented
Sperms Present Dripping in Threads
Foul Smell

 
It is Oliguria Albumin – Urea
Difficulty in passing Easy Discharge
Incontinence
It is Burning Pricking pain
Foul Smell Yes No
No. of Times Day Night
Hair Oil use Yes No
Whole Body Oil Bath Yes No
II. APPETITE
  Strong Poor Normal
  Veg Non Veg
  Timely Untimely
  Sleep Normal On Drug
III. DETAILS OF SURGERY
DETAILS OF SURGERY IF ANY?

IV. RECENT HISTORY OF ILLNESS /ACCIDENT  

Jaundice Yes No, When?
Typhoid Yes No, When?
Measles Yes No, When?
Accidental Injury Yes No, When?
Any Surgery Yes No
Migraine/ Head Ache Yes No
Fit/ Epilepsy Yes No
Any congential Disorder? Yes No
V. FAMILY HISTORY

(Any Hereditary Disease)
VI. PERSONAL HABITS
Habits Alcohol Drugs Snuff
Chewing Nuts Pan Parag Smoking
Beeda Jaritha Ganja Opium
VII. GENERAL EXAMINATION
Examination Obese Slim Normal
Oedema Skin Disease Anaemic
Warm or Cold & Sweating Body?
Any Handicap? Muscular Atrophy
Varicose Veins Filarial Swelling
FOR INFERTILITY CASES ONLY
VIII. SEXUAL ACTIVITY
GENTS
Organ Stiffstrong Weak
Small and Contracted Erection-Normal Non Erection Curved
Masturbation Regular Occasional
Before Marriage
      How Many Years?
Sex Intercourse Per Week Per Month
      No of times
Sexual Intercourse Difficult Unable Incomplete
Sex before marriage Yes No
Semen discharge During Sleep Urine
Semen Absence of semen Diluted Semen
Quick Ejaculation
Varicocele Lt Rt Bilateral
Varicocele Surgery done? Yes No
Testicular Biopsy if any? Yes No

If yes, Report sent by Mail now?

 Yes No
LADIES
Menses Periods Regular Late Stopped,
      at Age
Monthly Menses Discharge Only on taking Madicine
Also stopped by Medicine
Menses Cycle Regular Irregular, Flow for days
Profuse Scanty flow Painful
Colour Red Black Brown Clots Present
Foul Smell Yes No
Stain on Cotton Clothes Yes No
Whites Discharge Regular Rare Nil
Any D/C Done ?  Yes No
If  so how many times ?
Family planning surgery Yes No
Missed Abortions Yes No
Fibroid Yes No
F.Tube Block Test done ? Yes No
Uterus Removed Yes No, at Age
Uterus , Ovaries size in m.m  scale  ----------
(Radiology Reports to be sent by Mail)  		Uterus

Ovaries
Any Lap Surgery done for PCOS Yes No
Chocolate cyst? Yes No
IX. CLINICAL TEST : SEMEN ANALYSIS
Test Date
Count
Active Motility %
Survival after 3 hours %
Azoospermia Yes No
All Dead Sperms Yes No
Oligospermia Yes No
Reports XRAY USG CT MRI SCAN
ENDOSCOPY ETC. RPTS Sent by Mail
IX. CASE SUMMARY AND DIAGNOSIS
CASE SUMMARY AND DIAGNOSIS BY ALLOPATHY DOCTORS
IMPORTANCE NOTICE

Hospital reserves the right and discretion to admit or reject a patient on his/her fittness or unfittness for treatment.

   
 (This Document is strictly confidential & conditions applicable to all  Patients)