Call Us at: 03173085145

Home
About us
Shop
Contact us

Login / Register

0 items / ₨ 0

Female Problems Form

Home » Online Hakeem » Female Problems Form

Name

Email

Age

Weight (Kg)

Mobile Phone No

City

Country

Profession

Marital Status

Describe your main problems for which you want to seek our advice.

For how long, are you suffering from these problems?

How is your physique?

How is your Appetite?

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

Are you addicted to any other intoxicant (e.g., liquor/wine etc.)?

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 sensation while passing urine?

Yes No

How is the flow of urine?

Yes No

Do you suffer from Involuntary Urination?

Yes No

Do you suffer, or have you ever suffered from any venereal disease (Syphilis / Gonorrhoea)?

Yes No

Does any mucous (pus / fluid) pass out with urine?

Yes No

Are you having problem of white discharge (particularly leucorrhoea)?

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 in the morning?

Yes No

Are the menstrual periods regular?

Yes No

Are the menstrual periods painful?

Yes No

Are you presently pregnant?

Yes No

___If yes, mention the date of last menses.

Has there been any miscarriage?

Yes No

___If so, how many times

Any child born after miscarriage?

Yes No

Have you ever suffered from fainting or convulsive fits?

Yes No

___If so, name it

Do you still get such fits?

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 yes, name it.

Is there any history of hereditary diseases in the family?

Yes No

Upload Your Medical Report

Facebook Instagram Tiktok Youtube Whatsapp

2024 All Rights reserved.

Menu
Categories

Men’s Health

Home
Shop
Contact us
Login / Register

Shopping cart

Sign in

Username or email address *

Password *

Lost your password? Remember me

No account yet?

Create an Account

Facebook Instagram YouTube WhatsApp WhatsApp TikTok

Start typing to see products you are looking for.