General Check-Up Template

Patient Information

• Patient Name: PATIENT_NAME
• Age / DOB: _________
• Gender: _________
• Contact Number: _________
• Date of Visit: SESSION_DATE

Chief Complaint / Reason for Visit

Fever for the last three days, abdominal pain for the last three days, loss of appetite, cold and cough for the last two days.

Medical History

Chronic Illnesses (if any):

• Diabetes
• Hypertension
• Asthma
• Thyroid Disorder
• Other: _____

Surgeries / Hospitalizations:

Current Medications:

Allergies (Drugs/Food):

Lifestyle Details

• Smoking: ☐ Yes ☐ No
• Alcohol Consumption: ☐ Yes ☐ No
• Exercise Routine: ☐ Regular ☐ Occasional ☐ Sedentary
• Diet: ☐ Balanced ☐ High-Fat ☐ Low-Carb ☐ Vegetarian ☐ Other: Avoid spicy and fried food

Vital Signs

General Physical Examination

• Appearance: ☐ Well ☐ Pale ☐ Fatigued
• Eyes: ☐ Normal ☐ Redness ☐ Jaundice
• Ears/Nose/Throat: ☐ Normal ☐ Infection
• Skin: ☐ Normal ☐ Rash ☐ Dryness
• Heart Sounds: ☐ Normal ☐ Murmur
• Lung Sounds: ☐ Clear ☐ Wheezing ☐ Crackles
• Abdomen: ☐ Soft ☐ Tender ☐ Distended
• Extremities: ☐ Normal ☐ Swollen
• Neurological: ☐ Alert ☐ Oriented ☐ Other: __________

Investigations (If Needed)

• ☐ Blood Test
• ☐ Urine Test
• ☐ ECG
• ☐ Chest X-Ray
• ☐ Others: _____ __________

Assessment / Diagnosis

Treatment / Medications Prescribed

Advised medication (specific medications not detailed in the transcript).

Doctor's Advice & Recommendations

• ☐ Healthy Diet
• ☐ Regular Exercise
• ☐ Hydration
• ☐ Stress Management
• ☐ Follow-up Visit on: ___