Spamoksha

New User Register Now!

Home >> Online Consultation

Online Questionnaire

Name
Postal Address
Email Address
Gender	Age :
Height
Weight
Occupation
Marital Status
Your recent concerns/ Short description of present complaints with the duration
Diagnosis ( if done ) according to Modern medicine
Details about the Laboratory investigation, if any
Do you suffer from any of the following (High B.P / Cancer / Arthritis/ Asthma / Allergy)? If yes, duration & details of medication, if any
Appetite
Sleep
Bowel habits
Urination
Diet regime
Addiction: Tobacco / Alcohol / drugs (Anti-depressants etc.)
Any History of operations? If yes, details
Additional Questions for females:
Menstrual History		Regular / Irregular Heavy bleeding / Normal bleeding/ Scanty bleeding Painful / Painless Constitution….Normal/blackish/fragmented/foul smelling etc. Menopause (if occurred, when)
Family History:
Diabetes Mellitus
High Blood pressure
Cancer
Arthritis
Asthma
Allergy

Any other comments