CONSULTION FORM |
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Submit this form only in case of first time treatment. |
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Please conract with us over phone of through e-mail in case of an old patient Having any queries. |
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Fields marked with an asterix (*) are mandatory. |
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Name of the Patient | : | |
Date of Birth | : | |
Age of the patient | : | |
Sex | : | MALE / FEMALE |
Occupation |
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Present Address (with country and postal code) |
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Delivery Address for sending Medicine |
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Contact Numbers (with country and area code) |
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a) Mobile |
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b) Home Phone |
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c) Work Phone | : | |
d) E-mail Address | : |
Description of your symptoms: |
Treatment record, Laparoscope Report, H.S.G. Report, U.S.G. Report are required to start the treatment. Please enter a detailed description of your symptoms in the relevant boxes bellow. If you need more information, we will contact with you either over phone or e-mail. |
Case History |
Present Problem : |
Thyroid |
Cyst |
Abortion |
Tumour |
Endometrities |
Tumours in Overy |
Fallopian Tube Blockage |
Salpingo Opharities |
T.B. |
Menses :- | Early | Late | Regulay | Irregular | |
Duration - | Continuous discharge | Short | Long lasting | ||
Quatity - | Too scanty | Too profuse | Normal | ||
Character Blood – | Dark | Water | Red | Thick Clotted | |
Sensation - | Itching | Burning | Very much hot | ||
Pain – | Before Mense | After mense | During Mense | ||
Leucorrhoea :- | Yellowish | Milky white | Greenish | Acrid | |
Uterus :- | Fibroid | Cyst | Tumours | Endometritis | |
Scar tissue growth in Uterus | Prolapse | ||||
Overy :- | Overian small cyst | Multiple cyst | Tumours | Overities | Poly cystic Follicular cyst. |
Fallopian Tubes Blockage :- | Salpingo opharities | Gonorrhoea | Hydro Salpingities | Syphilis | Endometriosis T.B. |
Past disease history ; |
T.B. |
Threatened abortion |
Habitual abortion |
Measles |
Jaundice |
Mental trouble |
Mumps |
Skin disease |
Typhoid |
Surgery if any |
Family disease history; |
Syphilis |
Gonorrhoea |
T.B. |
Cancer |
Overian cyst |
Fibroid in uterus |
Tumour |
Thyroid |
Hypertension |
Diabetes |
Vaccination :- | Measles | Hepatitis | B.C.G. | Triple antigen | |
Thirst :- | Profuse | Scanty | No thirst | ||
Appetite :- | Less | Very hungry | Normal | Nil | |
Stool :- | Soft | Medium | Hard | With strain | Water like |
Urine :- | Yellow | Clear | Reddish | ||
Body :- | Thin | Obesity | Medium | Skiny | |
Time of rise of symptoms :- |
Morning | Evening | Midday | Midnight | |
Dreams :- | Ghosts | Dead people | Rats | Exams | Thieves |
Lateralities :- | Right sided | Left sided | |||
Nature :- | Irritable | Angry | Crying | Emotional | |
Melaneholic | Suicidal | Hopeless | Talkative | Fastidious | |
Lazy | Anxious | Grief | Fearfull | Religious | |
Feel better in :- | Winter | Summer | Monsoon | Seaside | |
Likes :- | Cold | Warm | Open air | Company | |
Addiction :- | Alcohol | Smoking | |||
Current Medication for :- |
Birth Control | Hypertension | Asthma | ||
Diabetes | Insomnia | Acididy | |||
Cravings :- | Cold drinks | Hot drinks | Warm food | Cold | |
Food | Salt | Sweet | Meat | ||
Unusual things | (Paper/Soil). |