Your Name (required)
Age :
Gender :
Address
City
State
Postal code
Country
Phone no
Email
Height
Weight ( In Kg or Pounds )
Occupation
Name of your Disease ( As Diagnosed by Medical Consultant )
Chief Complaint About Your Problems
Signs or Symptoms
How long you are suffering from (Years Months Days )
For Skin Problems - Which Areas have Affected
For Skin Patients (Do You Feel Pain, Itching, Any Blood Or Watery Discharge From Lesions )
Dietary Details ( About your Breakfast, Lunch & Dinner )
Your Food and life style habits ( Veg, Non-Veg, Overeating, Less-eating etc. )
Any food or weather Increase or decrease your problem
Presently On Medicines ( Write the name of medicines presently you are taking & from How long )
Are you Suffering from any other health problem (Diabetic , Hypertension , Heart Problem , Any Other Disease etc)
Appetite (Normal , Low , High)
Bowel Movements ( Like Acidity , Constipation , Normal , Regular , Irregular , Other Problems Etc.)
Urinary System ( Color of Urine , Frequency ,Burning Sensation )
Sleep ( Sound , Normal , Disturbed , Insomania )
Mental/ Emotional Condition ( Anxious, Nervous , Worrisome , Depressed ,Tense , Relaxed , Irritable ,Impatient , Patient , Calm ,Lethargic , Energetic, Restless )
Previous Medical History ( Have you been treated for any other disease previously )
Results of that treatment
How do you find us ( Google Search , YouTube , Google Ads ,FaceBook , Friend's Suggestion , Any Social Media )
Anything more you want to tell about your health problem
You May Write your Problems in Details if you want to tell our Doctors more about your health issue.