SUBMIT YOUR VERY BASIC CASE DETAILS (Your basic physical and or mental symptoms goes here)
Please Fill This For Your Basic Information
Email *
Your Name : *
Your Country and City. *
Gender *
Age *
Occupation (This is often relevant to your health as are unusual hobbies) *
Any addictions?
Whats-App Number / Phone Number, and Address *
Details about your present Disease in order of appearance with duration *
Your General Nature :(Anger, extrovert or introvert, emotional, decision making quality, suffering from indecision, childhood nature, how you take criticism etc.)
Past Disease History Since Your Childhood
Are You Suffering From _
Your Dreams While Sleeping
Any Surgery Done?
If you have already seen a doctor, what diagnosis did they give you?
What investigations, tests have you undergone? Please mention the reports and brief treatment history.
Is there anything else that might be helpful or relevant to your problem? including allergies, illnesses that run in the family and a little bit about your lifestyle.
Height
Weight
Which weather you prefer most ?
Appetite :
Thirst :
Liking for specific taste/food :
Urine :
Stool :
Perspiration :
Sleep pattern and or position during sleep :
Sensitivity :(To noise/ light/ sunlight/ high neck, ties/ narrow places/ closed rooms/ traveling in vehicles/ by air/ perfumes/ dust/ others)
Female Problems
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.