Asthma prevention
Alternate Therapy
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Case History
Case History form
Fields marked with a * are mandatory
Name : *
Age :*
Occupation : *
Address :*
You are a
: Smoker
Non-Smoker
Complaints
Duration of symptoms
Frequent
Infrequent
Occasional
Cough
Yes
No
Breathlessness
Yes
No
Wheeze
Continous
Nocturnal
Morning tightness
Excercise
Sputum
White
Yellow
Blood tinged
Running Nose
Yes
No
Itching
Yes
No
Skin lesions
Urticaria
Eczema
Activity
Normal
Run short distance
Indoors
Walking only
Tenderness over thoracic spine
Absent
Present
Stimulation over tender spine
Gives relief
No relief
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