Baqai Healthcare

Enquiry


CUPPING SESSION FORM

* fields are mandatoryDetails Information
Name of the Patient *  
Age *  
SEX   Male Female
Weight  
Height  
Profession * 
Marital status   Married     UnMarried
Email ID *  
Complete Postal Address  
City * 
State *  
Pin Code  
Country * 
Describe your main problem for which you want to seek advice  
For how long,are you suffering from these problems  
How is your physique   Fat     Slim
How is your appetite  Good    Poor
Motion Habit  Constipation    Loose    Normal
Type of food that you eat   Veg    Non Veg   mixed
Do you consume tobacco in any form  Yes    No
Are you addicted to any other intoxicant (eg: wine,alcohol/smoking)   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 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 you have recently undergone a medical check-up pertaining to blood,urine,stool,sputum,any X-ray/ultrasonography,please mention the information here  
Any other problem that you might like to state  
Is there any history of hereditary disease in the family  Yes    No
If yes mention it