| Night Sweats : | ? | |
| Evening rise of temperature : | ? | |
| Relieved on taking Antipyretics : | ? | |
| Cough : | ? | |
| Loose : | ? | |
| Vomiting : | ? | |
| Pain on Passing Urine : | ? | |
| Sore Throat : | ? | |
| Shortness of Breath : | ? | |
| Chest Pain : | ? | |
| Loss of Weight : | ? | |
| Loss of appetite : | ? | |
| Any Blood in Sputum : | ? | |
| Weakness : | ? | |
| Enlarged lymph nodes cervical : | ? | |
| Enlarged lymph nodes axillary : | ? | |
| Enlarged lymph nodes inguinal region : | ? | |
| History of smoking : | ? | |
| Any other Signs or Symptoms : | | |
| Additional history, in case of child |
|---|
| Feeding well : | ? | |
| Active : | ? | |
| Weight Loss in last 3 months : | ? | |
| Failure to gain weight in last 3 months : | ? | |
| Recurrent Abdominal Pain : | ? | |
| Seizures : | ? | |
| Irritability : | ? | |
| Lethargy : | ? | |
| Drowsiness : | ? | |
| Any other, Please Specify : | | |
