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Name of the Patient *
Please enter the name of the Patient.
Age * (Yrs.)
Please enter the age of the Patient.Invalid format.
Sex *
Please select a valid item.Please select Sex.
Weight (Kg)
Height (e.g. 5 feet, 7 inches)
Profession
Marital Status
Email *
Please enter your Email address.Invalid format.
Complete Postal Address
City
State
Zip
Country *
Please select a valid item.Please select country.
1. Describe your main problems for which you want to seek our advice. *
Please describe your main problems.
2. For how long, are you suffering from these problems ?
3. How is your physique ? Please make a selection.
4. How is your appetite ?
5. Do you have constipation ?
6. Type of food that you eat.
7. Do you consume tobacco in any form ?
8. Are you addicted to any other intoxicant
(e.g., liquor/wine etc.) ?
9. Do you take excessive quantity of tea
or coffee ?
 
10. Do you suffer from sleeplessness ?  
11. Do you suffer from excessive urination ?  
12. Do you feel any irritation or burning sensation while passing urine ?  
13. Do you feel palpitation of heart or pain in
chest or breathlessness during physical
exercise ?
14. Are you a patient of High Blood Pressure ?*  
Please select a valid Answer.Please Select yes / no.
15, If yes, mention your blood pressure. Systolic / Diastolic
16. Are you suffering from Diabetes ?*  
Please select a valid Answer.Please Select yes / no.
17. If yes, mention Blood Sugar

18. Have you suffered from any disease earlier ?
19. If yes, Name it.
20. If you have recently undergone a medical check-up pertaining to blood, urine, stool, sputum, any x-ray / ultrasonography, please mention the related reports.
21. Any other problem that you might like to state.
22. Is there a history of any hereditary disease in the family ? Systolic / Diastolic
23. If yes, mention it.
 
   

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