Consultation for Female Patient If you are a female and suffering from sexual or gynae related disease.Please choose this option.
Name of the patient
Age
(Yrs.)
Weight
(Kg)
Height
e.g 5 feet 7 inches
Profession
Marital Status
Email Address
Complete Postal Address
City
State
Zip
Country
Date of marriage?
(DD/MM/YYYY)
Number of children?
Age of eldest child
e.g. 3 Yrs.5 Months
Age of youngest child
e.g. 3 Yrs.5 Months
How is your physique?
Has there been any miscarriage?
Yes No
If so, how many times?
Any child born after miscarriage?
Yes No
Have you ever suffered form fainting or convulsive fits?
Yes No
If so, was it-
Do you still get such fits?
Yes No
Are the menstrual periods regular?
Yes No
Are they painful?
Yes No
Are you presently pregnant?
Yes No
If yes,mention the date of last menses?
(DD/MM/YYYY)
Do you feel any irritation or burning sensation while passing urine?
Yes No
Is your Urine colour yellowish?
Yes No
Does any mucus (fluid/pus/white discharge) pass out in urine?
Yes No
Are you having problem of white discharge (leucorrhoea) in particular?
Yes No
Do you feel pain in the back?
Yes No
Do you feel pain below the naval?
Yes No
Do you have complaints of nausea or vomiting sensation in the morning?
Yes No
How is you appetite?
Good Poor
Do you have constipation?
Yes No
Do you feel any burning sensation in chest/abdomen?
Yes No
Do you consume tobacco in any form?
Yes No
Is there any history of hereditary disease in the family?
Yes No
Mention it
Do you suffer or have you ever suffered from any venereal disease (Syphilis, Gonorrhoea)?
Yes No
Is your husband suffering or has ever suffered any venereal disease (Syphilis, Gonorrhoea)?
Yes No
If yes, indicate the exact nature of the disease
Are you diabetic?
Yes No
If yes, mention sugar level in blood
in urine
Are you a patient of Hypertension?
Yes No
If yes, mention your blood pressure
Consultation
Genral Male Female
Important :
If you have recently undergone a medical check-up pertaining to Sputum, phlegm, blood, urine or any X-ray, please mention the related reports
Any other problem that you might like to state
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