Height Increase Form
Please fill this form in complete and accurately, so that we can help you properly. For urgent responses, call at 91-9313520295 or mail at mediplex@gmail.com. The first section is for treatment purpose and necessary to fill. The second section is optional.
For appointments please call at 91 (India Code)- 9999013449. Talk to reception and ask for appointment for height increase program.
Name *
Your answer
Age (years) *
Your answer
Height (in Centimeters)
in centimeters i.e. 1 inch = 2.54 cms
Your answer
Your Gender
Enter M for Male or F for Female.
Weight
Enter your weight in KG
Your answer
email Id *
Your answer
Date of birth
MM
/
DD
/
YYYY
Date of filling form
MM
/
DD
/
YYYY
Pin code/Zip Code or postal code
Your answer
Enter Your Phone number for contact
example: country code- phone number. 91-9313520295
Your answer
Describe your problems
Discuss your issues medical issues
Your answer
Your father's height (approx) (in Centimeters)
in centimeters
Your answer
your mother's height (in Centimeters)
In centimeters
Your answer
Your brother's or sister's height
If more than 1 brother or sister- use next question as well
Your answer
Enter your all sibling's height (in Centimeters)
Enter the height of brothers and sisters as following: B1-162,B2-165,S1-163,S2-178,B3-158
Your answer
Your Maternal Grand Father's height (in Centimeters)
Your answer
Your Maternal Grand Mother's height (in Centimeters)
Your answer
Your Paternal Grand Father's height (in Centimeters)
Your answer
Your Paternal Grand Mother's height
Your answer
Any History of the following conditions- (If answer of any of the following is yes/affirmative then you must describe your complaints in the next section.)
Describe your conditions i.e. short parents, poor nutrition etc.
Your answer
For research Purpose only-Optional Section
The following questions are optional only for research purposes. We will keep your identity protected. As an incentive you will get 10 % discount on the treatment program.
Enter your partner's height-If married or engaged or have boy friend or girlfriend
M(Husband, fiancee, boyfriend)-height in cms or F(Wife, fiancee, girlfriend)-height in cms
Your answer
How is your confidence level ? Checking your self esteem on Rosenberg scale
We want to check whether height has any effect on your confidence ? Use scale properly.
Statement
Strongly Agree
Agree
Disagree
Strongly Disagree
I feel that I am a person of worth, at least on an equal plane with others.
I feel that I have a number of good qualities.
All in all, I am inclined to feel that I am a failure
I am able to do things as well as most other people.
I feel I do not have much to be proud of.
I take a positive attitude toward myself
On the whole, I am satisfied with myself.
I wish I could have more respect for myself.
I certainly feel useless at times.
At times I think I am no good at all.
Self Esteem Score- Previous question
Scores are calculated as follows: For items 1, 2, 4, 6, and 7: Strongly agree = 3 Agree = 2 Disagree = 1 Strongly disagree = 0; For items 3, 5, 8, 9, and 10 (which are reversed in valence): Strongly agree = 0 Agree = 1 Disagree = 2 Strongly disagree = 3; The scale ranges from 0-30. Scores between 15 and 25 are within normal range; scores below 15 suggest low self-esteem.
Your answer
Enter your Approximate Income/earnings etc. If you are not working select not working
It will be used only for research purposes. This question is to test the hypothesis to check whether tall people have more income than their counterparts
Use of Information Allowed for research
Without revealing your identity, we would like to use this information for our social sciences research on height.
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