TerraBlue XT - TJay Suite

1) How long have you been coughing for?

2) What is the colour of it?

Green Yellow White Grey Any other color
If any other color, Mention

3) When did you cough?

4) Does anything make coughing better or worse?

5) Have you noticed any blood in your sputum?

No Yes
If yes, How much blood is there in the cough? Is the quantity low or high? High Low

6) Are you short of breath when you cough?

No Yes

7) Is the cough accompanied by any chestpain or fever?

No Yes

8) Do you have any pets?

No Yes

9) Do you have a history of any heart problem?

No Yes

10) Does anyone in your family have asthma, eczema or any allergies?

No Yes

11) Is it worse at any particular time of the day, at night or morning? Morning Afternoon Evening Night During sleep

12) Does exercise, cold air or pollens make your coughing worse? Exercise Cold air Pollens Food Intake Any other
In case of any other

13) Do you feel a sharp chestpain that gets worse when you breathe in?

No Yes

15) How is your appetite? Normal, lower than usual, higher than usual

Normal Lower than usual diet Higher than usual diet

16) Do you see any fluctuation in your weight recently?

No Yes

17) Do you feel tired often?

No Yes

Mr. Vinod Sharma
DOB: 01/01/1978 (Age 37), Male

+91 97420 56787

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