Online Consulation

Name D.O.B
Sex Occupation
Height Weight
Marital Status
Email
Address Country
State City
Pincode
Mobile No Phone No
Chief Complaint With Duration

Complications or any other associated condition(s) -

Mode of Onset
Past History,please specify the detail of following(if any)



Family history/Personal history
of any of the following



Gynecological/Obstetric history

Number of pregnancies
Number of alive kids
Mode of delivery-Normal/Caesarian
Any Surgery (C/S, DNC, Partial or Complete Hysterectomy, etc)
Menstrual history


Diagnostic details

Name of the Doctor
Name of the Hospital
Place
Date of Diagnosis


Details of any medication (if any)

Past treatment
Current treatment
Life-style of the patient (before and after the diagnosis)

CONSTITUTION ANALYSIS PROFORMA

Body Built
Complexion
Skin Nature
Nature of Hair
Joint characteristics
Appearance of veins and tendons
Patient's body is
Temperature preferences
Eye
Nature of teeth and gums
Appetite
Preference for taste
Sweating
Excretory habits
Urination
Sleep
Psychological status
Memory