TREATMENT

CONSULTION FORM

Submit this form only in case of first time treatment.

Please conract with us over phone of through e-mail in case of an old patient Having any queries.

Fields marked with an asterix (*) are mandatory.
Name of the Patient :  
Date of Birth :  
Age of the patient :  
Sex :
MALE / FEMALE

Occupation

 :  
Present Address
(with country and postal code)		 :  

Delivery Address for sending Medicine
(if different from above)

 :  

Contact Numbers (with country and area code)

    
a) Mobile
 :  
b) Home Phone
 :  
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).