General Form

General 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

Do you feel palpitation of heart or pain in chest or breathlessness during physical exercise?

Yes No

Are you a patient of High Blood Pressure?

Yes No

Are you suffering from Diabetes?

Yes No

Have you suffered from any disease earlier?

Yes No

-----If yes, name it

Any other problem that you might like to state.

Send your medical report on this email : info@herbwiser.com

Upload Your Reports Here

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