| * Required fields |
| Name *
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| E-mail Address *
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| Phone number |
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| What country do you live in? * |
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| Sex * |
Male
Female
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| Age * |
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| Profession / occupation |
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| Maritial status * |
Single
Married
Unmarried
Divorced
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| Height (Ft. and Inches) * |
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| Weight (kgs) * |
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| Blood pressure ( mention date when last checked) |
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| You are a: * |
Vegetarian
Non-vegetarian
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| You are a smoker
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| You consume alcohol
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| Drug abuse
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| You drink tea/coffee
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| Please give details of what you are suffering from * |
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| Past History of ailment(s) |
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| Medication/ therapy taken so far & results: |
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| Any ailments your father/ mother/ any other family member suffering from |
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| Laboratory Investigation Reports (if any) |
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| USG/MRI/Scan Reports |
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| Are you suffering from any psychosomatic disorder eg. Depression, Stress, Mood disorder, Suicidal tendencies etc. Please give details if yes |
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| Other information which you think might be helpful |
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| Which of the following describes your appetite best? |
You feel very hungry
You do't feel very hungry
Sometimes hungry sometimes not
You eat just because it's time to eat
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| Your eating habits |
Specific times in a day
No regular timing
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| How many meals do you have in a day ? and specify your meal timings |
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| You don't have any taste preferences
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| You like sweet taste
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| You like salty taste
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| You like sour taste
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| You like spicy taste
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| You like pungent taste
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| You like astringent taste
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| Please give details of what you eat usually for your meals |
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| How many liters of water do you usually consume in a day? |
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| What is the type of water you usually consume? |
Cold
warm
room temprature
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| Bowel movements * |
You evacuvate everyday
You evacuvate once in 2 days
You evacuvate once in 3 or 4 days
You evacuvate once in a week
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| Time of evacuvation |
Similar time everyday
Different times everyday
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| Is there lot of gas during evacuation? |
Yes
No
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| Do the stools smell very bad? |
Yes
NO
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| Is there bleeding / mucous in the stools ? |
Bleeding
Mucous
Bleeding and Mucous
None of the above
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| How much time does it usually take to evacuate ? |
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| Colour and quantity of stools ? |
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| How many times do you urinate in a day? |
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| How many times do you wake up from your sleep to urinate? |
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| Colour of your urine is? * |
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| Any other colour, Please mention here |
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| Do you experience burning sensation, blood, sperm, white discharge or any other unusual things before, during or after urination ? give details if yes |
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| After how many days does your menstural cycle appear? what is the duration of your mensturation? give details |
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| What is the colour of your menstural blood? Red, Crimson red, Blackish, Brownish |
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| Your menstural bleeding is usually |
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| Do you suffer from clots, cramps, backache, fever, pain, mood fluctuations, any kind of discharges or any other problems during, before or after your periods? |
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| How many hours do you sleep in a day? * |
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| What times do you sleep and wake up? |
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| Quality of your sleep |
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| How many times do you dream in your sleep, in a week? |
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| What do you usually do before you go to bed? |
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| Any other complaints like talking or walking in your sleep? |
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| How many times do you have sexual intercourse in a week? |
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| Anything else you would like to mention about your sexual life? |
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| Your work involves |
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| Your work is more of |
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| Your work in |
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| Do you exercise? |
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| If you exercise, please metion what type of exercise you do and the duration |
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| Click if you are a very serious person
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| Click if you are happy go lucky
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| Click if you are a very cool and calm person
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| Click If you worry about small things
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| Anything else you would like to say to describe your personality |
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| Describe the climatic conditions you live in |
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