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Medical Enquiry Form

Please take a few minutes to fill out information on yourself, and the additional information/services that you are interested in. We will get in touch with you once we receive your inquiry.

Medical Enquiry Form

1 Name
2 Address :
3 Tel :
4 Occupation :
5 Birth Date : (MM/DD/YYYY)
Place of Birth :
6 Present Weight : KG
7 Diet : (Veg. / Non-Veg.)
8 Do You ? Smoke take alcohol chew tobacco
take pan
any other habits
Family History
Married  Unmarried
  b) Number of children :
  c) with normal / caesarian delivery
Dieses Father Mother Father's Father Father's Mother Mother's Father Mother's Mother
Diabetes
Asthama
B.P.
Heart
Cancer
Anybody else in the family suffering from specific diseases ?
9 Urination : a) normal frequent less bed wetting.
b) protein albumen  pus cells  sugar in urine.
c) burning sensation during urination Yes No
d) urine infection Yes No
10 Bowel motion habits : a) Normal loose motion constipated sticky
with blood painful very hard.
b) Frequency :
1 time a day more than 1 time a day.
c) Burning in chest and throat Yes No
11 Routine Pathology Check-ups : Blood Pressure (date ) Urea
Hemoglobin (date ) Creatin
Diabetes (Blood Sugar) (date )
Fasting
Post meal
12 Sleep : Normal  very little too much disturbed going to bed too late.
13 Menstruation & Gynecological problems :
    a) Regular irregular
b) Interval between two periods days. Discharge for days.
c) Discharge : Normal irregular scanty heavy black brown with foul smell.
d) Pain before during the cycle.
e) Do you observe M.C. rules e.g. not to mix with others, not to enter temples,serve food etc. ? Yes No
f) Is there white / red discharge ? Yes No Since a long time / Many days a month.
g) Has menstruation already stopped ? Yes No Since when
h) Uterus / Ovary : operated or removed. Yes No
When
i) Family planning operation. Yes No
When
14 MAJOR COMPLAINTS YOU HAVE :
A) BRAIN PROBLEMS : Epilepsy, Memory loss, Migraine, Headaches,
Vertigo,
Parkinson, Mentally Under developed
B) URINARY PROBLEMS : Diabetes, Kidney stones, Kidney failure,
Prostate, Gonorrhea
C) SKIN PROBLEMS : Pimples, Eczema, Psoriasis,
Varicose Veins,
Allergy, Leucoderma,
Leprosy
D) RESPIRATORY PROBLEMS : Tonsillitis, Asthma, Common cold,
Cough, Bronchitis, T.B.
E) HEART
PROBLEMS :
Blood pressure - High/Low, Enlarged heart, Hole in the Heart, Angina, Ischemia, Mistral stenosis,
Blocked arteries
F) DIGESTION PROBLEMS : Acidity, Ulcer, Indigestion, Gases,
Constipation,
Worms, Hepatitis (Kamla),
Liver, Spleen, Ascites, Piles, Fissure,
Fistula,
Amoebic dysentery, Colitis, Anorexia with vomiting.
G) SEXUAL PROBLEMS :
Spermatoza Ezospermia Oligospermia
Ipotence, Infertility, Hormonal Imbalance, Sexual disease, Blocked fallopian tubes,
Ovarian cyst, Myome Fibroids in uterus
H) VAATA, BONE, NERVE PROBLEMS : Arthritis, Osteo Arthritis, Spondilitis, Slipped disc, Sciatica, Gout, Paralysis, Bone T.B., Knee pain, Rheumatism, Polio, Back ache, Cancer
I) GENERAL PROBLEMS : a) EYE : increase in number, pigmentoza, night blindness, loss of sight, color blindness
b) EAR : pain, discharge, deafness, sound in ear
c) HAIR : loss of hair, baldness, dandruff, lice,
greying hair
d) TEETH : tooth ache, gum bleeding,
pyorrhea
e) Sore throat, ulcers in mouth, nose bleeding,
blockage of nostrils, sinusitis
f) Obesity, cholesterol, loss of weight
g) Thyroid problems
h) Fever, unhealing wounds
15 Are you already taking treatment? Yes No  If Yes, for what problems
Ayurvedic Allopathic Homoeopathic
Any other
Names of Drugs
16 Have you undergone any surgical operations ? Yes No 
If Yes, give details
17 FOR WHICH PARTICULAR PRESENT PROBLEM HAVE YOU COME TODAY ?

 

CONSULTING DOCTOR :
Dr. Atul Desai -
B.A.M.S., FIIM, M.D.(A.M.)

Reg. No. GBI 10366

 

 

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