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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? *
YES
NO
6. Do you feel any burning sensation in chest / abdomen? *
YES
NO
7. Do you consume tobacco in any form? *
YES
NO
8. Are you addicted to any other intoxicant (e.g., liquor/wine etc.)? *
YES
NO
9. Do you take excessive quantity of tea or coffee? *
YES
NO
10. Do you suffer from sleeplessness? *
YES
NO
11. Do you suffer from excessive urination? *
YES
NO
12. Do you feel any irritation or burning sensation while passing urine? *
YES
NO
13. How is the flow of urine? *
YES
NO
14. Do you suffer from Involuntary Urination? *
YES
NO
15. Do you suffer, or have you ever suffered from any venereal disease (Syphilis / Gonorrhoea)? *
YES
NO
16. Does any mucous (pus / fluid) pass out with urine? *
YES
NO
17. Are you having problem of white discharge (particularly leucorrhoea)? *
YES
NO
18. Do you feel pain in the back? *
YES
NO
19. Do you feel pain below the naval? *
YES
NO
20. Do you have complaints of nausea or vomiting in the morning? *
YES
NO
21. Are the menstrual periods regular? *
YES
NO
22. Are the menstrual periods painful? *
YES
NO
23. Are you presently pregnant? *
YES
NO
___If yes, mention the date of last menses.*
24. Has there been any miscarriage? *
YES
NO
___If so, how many times? *
25. Any child born after miscarriage? *
YES
NO
26. Have you ever suffered from fainting or convulsive fits? *
YES
NO
___If so, name it *
27. Do you still get such fits? *
YES
NO
28. Are you a patient of High Blood Pressure? *
YES
NO
___If yes, mention your blood pressure.*
29. Are you suffering from Diabetes? *
YES
NO
30. Have you suffered from any disease earlier? *
YES
NO
___If yes, name it.*
31. Is there any history of hereditary diseases in the family? *
YES
NO
___If yes, mention it.*
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