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.*