Baqai Healthcare - GENERAL CONSULTANCY FORM

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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
Do you have constipation	Yes No
Dietery Habit	Veg Non Veg Mix
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

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