PATIENT CONSULTANCY FORM

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

WAIT >>> THINK >>> FILL >>> SUBMIT

Email *

Name *

Gender *

Age in Year *

Mobile No. *

Whatsapp No.

Marital Status

City *

State

Country

Details about Present Disease / Ailments / Problem *

Duration / Order of Appearance of Disease

Is there any thing PECULIAR about your DISEASE / Problem ?

How / When the Disease Increases (Aggravate) ? -- ( Answer only if you are confirm )

How / When the Disease Decreases (Ameliorate) ? -- ( Answer only if you are confirm )

Is there any Effect by HOT / COLD / RAINY Weather ? -- ( Answer only if you are confirm )

Is there any Effect by HOT / COLD Drink ? -- ( Answer only if you are confirm )

Your LIKES or DISLIKES ? ( Answer only if you are confirm )

Appetite ( Hunger ) ( Choose any ONE )

Normal

Less

Clear selection

Thirst ( Choose any ONE )

Normal

Less

Clear selection

Urine / Urination ( Choose ONE or More than ONE )

Normal

Frequent

Less

Have OTHER Problem

Stool ( Choose ONE or More than ONE )

Normal

Constipation

Loose Stool

Have OTHER Problem

Perspiration ( Sweat / Paseena ) ( Choose any ONE)

Normal

Have Problem

Clear selection

Sleep ( Choose any ONE)

Normal

Have Problem

Clear selection

Menses / Periods ( for Female Only) ( Choose any ONE )

Normal / No Problem

Have Problem

Clear selection

If have Problem in Menses / Periods / Gynae , give detail ( for Female Only )

If you have already consulted a Doctor , what Diagnosis / Disease they declared ( if Any )

What Investigation / Test have you undergone ? Mention the Report & Brief Treatment History ( if any )

Is there any thing PECULIAR about YOU ??

Anything else you would like to share with Doctor ?

FIX APPOINTMENT / TIME of CONSULTATION ( Doctor will Call You On This Time over Mobile )

DATE of CONSULTATION *

YYYY

TIME of CONSULTATION ( INDIAN TIME ) *

MAKE PAYMENT OF CONSULTANCY CHARGE OF Rs.400/- for ONE MONTH.

(Pay Rs.400/- ONLY as Consultancy Charge , for ONE Month) >> Submit this FORM after Making PAYMENT.

Make Payment through any of these Option :---

1. For payment through Paytm >>>> Paytm Number >>>> 9973844415

2. For payment through UPI >>>> UPI ID >>>> rajanikr47@okhdfcbank

3. For payment through Google Pay >>>> 9973844415

4. For payment through >>>> Debit Card / Credit Card / Internet Banking

Click on >>>>

https://www.payumoney.com/paybypayumoney/#/3345E0C0FBCEEFF84A8DAFB65B593A5F

DATE of PAYMENT DONE and DETAILS of PAYMENT ( Fill ONLY after Making Actual Payment ) *

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

Forms

reCAPTCHA

Privacy Terms

This form was created inside of Dr. BINOD KUMAR Homoeopathic Consultancy Clinic.