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Female Problems Form
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* Indicates required question
Your Name
*
Your answer
Age
*
Your answer
Weight (Kg)
*
Your answer
Mobile Phone No
*
Your answer
Email
*
Your answer
City
*
Your answer
Country
*
Your answer
Profession
*
Your answer
Marital Status
*
Your answer
1.Describe your main problems for which you want to seek our advice.
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Your answer
2. For how long, are you suffering from these problems ?
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Your answer
3. How is your physique?
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Your answer
4. How is your appetite?
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Your answer
5. Do you have constipation?
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Yes
No
6. Do you feel any burning sensation in chest / abdomen?
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Yes
No
7. Do you consume tobacco in any form?
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Yes
No
8. Are you addicted to any other intoxicant (e.g., liquor/wine etc.)?
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Yes
No
9. Do you take excessive quantity of tea or coffee?
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Yes
No
10. Do you suffer from sleeplessness?
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Yes
No
11. Do you suffer from excessive urination?
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Yes
No
12. Do you feel any irritation or burning sensation while passing urine?
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Yes
No
13. How is the flow of urine?
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Yes
No
14. Do you suffer from Involuntary Urination?
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Yes
No
15. Do you suffer, or have you ever suffered from any venereal disease (Syphilis / Gonorrhoea)?
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Yes
No
16. Does any mucous (pus / fluid) pass out with urine?
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Yes
No
17. Are you having problem of white discharge (particularly leucorrhoea)?
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Yes
No
18. Do you feel pain in the back?
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Yes
No
19. Do you feel pain below the naval?
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Yes
No
20. Do you have complaints of nausea or vomiting in the morning?
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Yes
No
21. Are the menstrual periods regular?
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Yes
No
22. Are the menstrual periods painful?
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yes
No
23. Are you presently pregnant?
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Yes
No
___If yes, mention the date of last menses.
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Your answer
24. Has there been any miscarriage?
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Yes
No
___If so, how many times
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Your answer
25. Any child born after miscarriage?
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Yes
No
26. Have you ever suffered from fainting or convulsive fits?
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yes
No
___If so, name it
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Your answer
27. Do you still get such fits?
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Yes
No
28. Are you a patient of High Blood Pressure?
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Yes
No
29. Are you suffering from Diabetes?
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Yes
No
30. Have you suffered from any disease earlier?
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Yes
No
___If yes, name it.
*
Your answer
31. Is there any history of hereditary diseases in the family?
*
Your answer
Send your medical report on this email : hakeem@ajmalhealth.com
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