Your Name *

Age *

Sex *

Weight (Kg) *

Mobile Phone No. *

Email *

City *

Country *

Profession *

Marital Status *

1. Describe your main problems for which you want to seek our advice.*

2. For how long, are you suffering from these problems ?

3. How is your physique? *

4. How is your appetite? *

5. Do you have constipation? *
YESNO

6. Do you feel any burning sensation in chest / abdomen? *
YESNO

7. Do you consume tobacco in any form? *
YESNO

8. Are you addicted to any other intoxicant (e.g., liquor/wine etc.)? *
YESNO

9. Do you take excessive quantity of tea or coffee? *
YESNO

10. Do you suffer from sleeplessness? *
YESNO

11. Do you suffer from excessive urination? *
YESNO

12. Do you feel any irritation or burning sensation while passing urine? *
YESNO

13. How is the flow of urine? *
YESNO

14. Do you suffer from Involuntary Urination? *
YESNO

15. Do you suffer, or have you ever suffered from any venereal disease (Syphilis / Gonorrhoea)? *
YESNO

16. Does any mucous (pus / fluid) pass out with urine? *
YESNO

17. Are you having problem of white discharge (particularly leucorrhoea)? *
YESNO

18. Do you feel pain in the back? *
YESNO

19. Do you feel pain below the naval? *
YESNO

20. Do you have complaints of nausea or vomiting in the morning? *
YESNO

21. Are the menstrual periods regular? *
YESNO

22. Are the menstrual periods painful? *
YESNO

23. Are you presently pregnant? *
YESNO

___If yes, mention the date of last menses.*

24. Has there been any miscarriage? *
YESNO

___If so, how many times? *

25. Any child born after miscarriage? *
YESNO

26. Have you ever suffered from fainting or convulsive fits? *
YESNO

___If so, name it *

27. Do you still get such fits? *
YESNO

28. Are you a patient of High Blood Pressure? *
YESNO

___If yes, mention your blood pressure.*

29. Are you suffering from Diabetes? *
YESNO

30. Have you suffered from any disease earlier? *
YESNO

___If yes, name it.*

31. Is there any history of hereditary diseases in the family? *
YESNO

___If yes, mention it.*