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Name of the Patient *
Please enter the name of the Patient.
Age *
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Weight (Kg)
Height (e.g. 5 feet, 7 inches)
Profession
Email *
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Complete Postal Address
City
State
Zip
Country *
Please select a valid item.Please select country.
1. Marital Status
If Married  
(a) Date of Marriage
(b) No. of Children
(c) Age of eldest child
(d) Age of youngest child
(e) At present, are you living with your husband ? 
3. Describe your main problems for which you
want to seek our advice. *

A value is required.
4. How is your physique ?
5. How is your appetite ?
6. Do you have constipation ?  
7. Type of food that you eat.
8. Do you feel any burning sensation in chest / abdomen ?
9. Do you consume tobacco in any form ?
10. Are you addicted to any other intoxicant
(e.g., liquor/wine etc.) ?
 
11. Do you take excessive quantity of tea
or coffee ?
12. Do you suffer from sleeplessness ?
13. Do you suffer from excessive urination ?
14. Do you feel any irritation or burning
sensation while passing urine ?
15. How is the flow of urine ?
16. Do you suffer from Involuntary Urination ?  
17. Do you suffer, or have you ever suffered from any venereal disease (Syphilis / Gonorrhoea) ?  
18. Does any mucous (pus / fluid) pass out with urine ?
19. Are you having problem of white discharge (particularly leucorrhoea) ?  
20. Is your husband suffering or has ever suffered from any venereal disease (Syphilis, Gonorrhoea) ?  
21. If yes, indicate the exact nature of the disease.
22. Do you feel pain in the back ?  
23. Do you feel pain below the naval ?
24. Do you have complaints of nausea or
       vomiting in the morning ?
25. Are the menstrual periods regular ?*
Please Select yes / no.
26. Are the menstrual periods painful ?  
27. Are you presently pregnant ?
28. If yes, mention the date of last menses.
29. Has there been any miscarriage ?
30. If so, how many times ?
31. Any child born after miscarriage ?
32. Have you ever suffered from fainting or convulsive fits ?
33. If so, was it
34. Do you still get such fits ?
35. Do you suffer from High Blood Pressure ?*
Please Select yes / no.
36. If yes, mention your blood pressure.
37. Are you suffering from Diabetes ?*
Please Select yes / no.
38. If yes, mention Blood Sugar :
39. Have you suffered from any disease earlier ?
40. If yes, name it.
41. Is there any history of hereditary diseases in the family
42. If yes, mention it.
43. If you have recently undergone a medical check-up pertaining to blood, urine, stool, sputum, any x-ray, ultrasonography, etc., please mention the related reports.
44. Any other problem that you might like to state.
   

   
Female Problems
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 

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