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Female Problems Form

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Female Problems Form

Female Problems Formweb team2019-05-28T11:44:09+05:00

Female Problems Form

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.*

Product categories

Arqiyat
Blood and Skin Diseases
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Constipation
Consumer Products
Deficiency of Calcium
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Disease of Intestines
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Diseases of Children
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- High Blood Pressure
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Diseases of the Liver
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Diseases of the Throat
Diseases of the Uterus and Hysteria
Dysentery
Eye Care
Fever Medicine
General Diseases
Gonorrhoea
Hab
Hair Care
Health Kit
Herbs
Honey
Hysteria
Illnesses due to Masturbation
Inflammation of the Uterus
Insomnia
Ispaghol
Itrifal
Jawarishat
Joint Care
Khameera
Kidney and Bladder Care
- Stones of Kidneys and Bladder
Labub
Laooq
Leucoderma
Majun
Male Health
Mashroobat
Meningitis
Nocturnal Emission
Obesity
Oil
Parkinson’s Disease
Piles
Pleasure and Increasing Time
Qurs
Roghaniyat
Safoof
Spermatorrhea and Oversenstive Penis
Stomach Care
Syphillis
Tila
Venereal Disease
Weakness of the Uterus and Miscarriage
Weight Loss
Women Care
Zamad

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PHONE: +92-42-37120542
+92-3074409221
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