Female Problems Form

Name

Email

Age

Weight (KG)

Mobille Phone NO

City

Country

Profession

Marital Status

Describe your main problems for which you want to seek our advice.

For how long, are you suffering from these problems?

How is your physique?

How is your appetite?

Do you have constipation?

Yes No

Do you consume tobacco in any form?

Yes No

Are you addicted to any other intoxicant (e.g., liquor/wine etc.)?

Yes No

Do you take excessive quantity of tea or coffee?

Yes No

Do you suffer from sleeplessness?

Yes No

Do you suffer from excessive urination?

Yes No

Do you feel any irritation or burning sensation while passing urine?

Yes No

Does any mucous (pus / fluid) pass out with urine?

Yes No

Are you having problem of white discharge (particularly leucorrhoea)?

Yes No

Do you feel pain below the naval?

Yes No

Do you feel pain in the back?

Yes No

Are you presently pregnant?

Yes No

Are the menstrual periods painful?

Yes No

Are the menstrual periods regular?

Yes No

Do you have complaints of nausea or vomiting in the morning?

Yes No

Do you still get such fits?

Yes No

___If yes, mention the date of last menses.

Any child born after miscarriage?

Yes No

Have you ever suffered from fainting or convulsive fits?

Yes No

Are you a patient of High Blood Pressure?

Yes No

re you suffering from Diabetes?

Yes No

Have you suffered from any disease earlier?

Yes No

Is there any history of hereditary diseases in the family?

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