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 consume tobacco in any form? * YESNO
7. Are you addicted to any other intoxicant (e.g., liquor/wine etc.)? * YESNO
8. Do you take excessive quantity of tea or coffee? * YESNO
9. Do you suffer from sleeplessness? * YESNO
10. Do you suffer from excessive urination? * YESNO
11. Do you feel any irritation or burning sensation while passing urine? * YESNO
12. Do you feel palpitation of heart or pain in chest or breathlessness during physical exercise? * YESNO
13. Are you a patient of High Blood Pressure? * YESNO
14. Are you suffering from Diabetes? * YESNO
15. Have you suffered from any disease earlier? * YESNO
(a) ------If yes, name it.
16. Any other problem that you might like to state.*
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