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.*
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