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FEMALE CONSULTATION FORM

* fields are mandatoryDetails Information
Name of the Patient *  
Age * 
Weight  
Height  
Profession *  
Email ID *  
Complete Postal Address  
City*  
State *  
Pin Code  
Marital status   Married     UnMarried
Describe Your Problem for which you want to seek advice?  
Is there any past history have you suffered from any disease earlier?  
Do you suffer from High Blood Pressure   Yes     No
Are you suffering from diabetes?   Yes    No
How is your physique?   Fat    Slim    Average
Motion Habit  Constipation    Loose    Normal
Dietery habbit   Veg    Non Veg   Mixed
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
How is the flow of urine   Smooth   Restricted
Are you addicted to any other intoxicant (eg: wine,alcohol/smoking)   Yes   No
How is your appetite  Good    Poor
Are the menstrual periods regular   Yes    No
Are you having problem of white discharge  Often    Sometime     Never
Is your husband suffering or ever suffered from any vulnerable disease(eg: syphilis, gonorrhoea)   Yes    No
Do you feel pain in the back  Often     Sometime    Never
Do you suffer from headache  Often    Sometime    Never
Do you have complaint of nausea & vomiting in the morning  Often    Sometime     Never
Are you presently pregnant  Yes    No
If yes how many weeks  
Has there been any miscarriage   Yes   No
If yes how many times  
Do you feel pain in abdomen  Often     Sometime    Never
Do you have child   Yes   No
If yes how many  
Female  
Male  
Do you feel pain in legs (calf muscles)   Often    Sometime    Never
Have you suffered from any disease earlier  Yes    No
Is there any history of hereditary disease in the family  Yes    No
If you have undergone any medical investigations, kindly mention here  
Any other, which you would like to describe  
   

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Baqai Healthcare

3070,PARKING GOLCHA CINEMA,DARYA GANJ,NEW DELHI, Darya Ganj, - 110002, India

Mobile : +91-9811436517, +91-9899641514

Phone : +91-11-23262757

Call Us : 08048771135

E-mail : baqaidawakhana@gmail.com



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