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FEMALE CONSULTATION FORM

Products

Baqai Artho-Guard Oil
Baqai Halwa Gheekwar
Baqai Hazim Powder
Baqai Hazim Chatni
Baqai Healto Care Tonic
Baqai Herbal Syrup
Baqai Herbal Tablets
- Baqai Consti Care Tablets
- Baqai Jiryani Go Tablets
Baqai Khamira Dimagi Sona Chandi
Baqai Musli Aloe Vera Power Prash
Baqai Obe-Fit Pills
Baqai Shilajeet

Baqai Healthcare

3070,PARKING GOLCHA CINEMA,DARYA GANJ,NEW DELHI, Darya Ganj, - 110002, India

Call Us : View Mobile Number

Phone : +91-11-23262757

E-mail : baqaidawakhana@gmail.com

* fields are mandatoryDetails Information
Name of the Patient *
Age *
Weight
Height
Profession *
Email ID *
Complete Postal Address
City*
State *
Pin Code
Marital status	Married UnMarried
Describe Your Problem for which you want to seek advice?
Is there any past history have you suffered from any disease earlier?
Do you suffer from High Blood Pressure	Yes No
Are you suffering from diabetes?	Yes No
How is your physique?	Fat Slim Average
Motion Habit	Constipation Loose Normal
Dietery habbit	Veg Non Veg Mixed
Do you suffer from sleeplessness	Yes No
Do you suffer from excessive urination	Yes No
Do you feel any irritation or burning while passing urine	Yes No
How is the flow of urine	Smooth Restricted
Are you addicted to any other intoxicant (eg: wine,alcohol/smoking)	Yes No
How is your appetite	Good Poor
Are the menstrual periods regular	Yes No
Are you having problem of white discharge	Often Sometime Never
Is your husband suffering or ever suffered from any vulnerable disease(eg: syphilis, gonorrhoea)	Yes No
Do you feel pain in the back	Often Sometime Never
Do you suffer from headache	Often Sometime Never
Do you have complaint of nausea & vomiting in the morning	Often Sometime Never
Are you presently pregnant	Yes No
If yes how many weeks
Has there been any miscarriage	Yes No
If yes how many times
Do you feel pain in abdomen	Often Sometime Never
Do you have child	Yes No
If yes how many
Female
Male
Do you feel pain in legs (calf muscles)	Often Sometime Never
Have you suffered from any disease earlier	Yes No
Is there any history of hereditary disease in the family	Yes No
If you have undergone any medical investigations, kindly mention here
Any other, which you would like to describe

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