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FAQ
Female Form (Consultation Form for Gynaecological Problems)
Fields marked with an asterisk (*) are required.
 
*Name of the Patient
*Age   (Yrs.)
Weight   (Kg)
Height   (e.g., 5 feet, 7 inches)
Profession
*Email Address
Complete Postal Address
City
State
Zip
*Country
1. Marital Status   Married    Unmarried
2. If married,  
  (a) Date of Marriage     (DD / MM / YYYY)
  (b) No. of Children   
  (c) Age of eldest child  
  (d) Age of youngest child  
  (e)  At present, are you living with your husband ?   
Yes No
*3. Describe your main problems for which you
    want to seek our advice.
4. How is your physique ?
Fat Slim
5. How is your appetite ?
Good Poor
6. Do you have constipation ?
Yes No
7. Type of food that you eat.
Veg. Non-Veg.
8. Do you feel any burning sensation in chest /
    abdomen ?
Yes No
9. Do you consume tobacco in any form ?
Yes No
10. Are you addicted to any other intoxicant
    (e.g., liquor/wine etc.) ?
Yes No
11. Do you take excessive quantity of tea
      or coffee ?
Yes No
12. Do you suffer from sleeplessness ?
Yes No
13. Do you suffer from excessive urination ?
Yes No
14. Do you feel any irritation or burning
      sensation while passing urine ?
Yes No
15. How is the flow of urine ?
Smooth Restricted
16. Do you suffer from Involuntary Urination ?
Yes No
17. Do you suffer, or have you ever suffered
      from any venereal disease (Syphilis /
      Gonorrhoea) ?
Yes No
18. Does any mucous (pus / fluid) pass out
      with urine ?
Yes No
19. Are you having problem of white discharge
      (particularly leucorrhoea) ?
Yes No
20. Is your husband suffering or has ever
      suffered from any venereal disease (Syphilis,
      Gonorrhoea) ?
Yes No
21. If yes, indicate the exact nature of the
      disease.
22. Do you feel pain in the back ?
Yes No
23. Do you feel pain below the naval ?
Yes No
24. Do you have complaints of nausea or
       vomiting in the morning ?
Yes No
25. Are the menstrual periods regular ?
Yes No
26. Are the menstrual periods painful ?
Yes No
27. Are you presently pregnant ?
Yes No
28. If yes, mention the date of last menses.   (DD / MM / YYYY)
29. Has there been any miscarriage ?
Yes No
30. If so, how many times ?
31. Any child born after miscarriage ?
Yes No
32. Have you ever suffered from fainting
      or convulsive fits ?
Yes No
33. If so, was it   (before marriage / after marriage)
34. Do you still get such fits ?
Yes No
35. Do you suffer from High Blood Pressure ?
Yes No
36. If yes, mention your blood pressure.   (Systolic / Diastolic)
37. Are you suffering from Diabetes ?
Yes No
38. If yes, mention Blood Sugar :
Fasting PP Random
39. Have you suffered from any disease earlier ?
Yes No
40. If yes, name it.
41. Is there any history of hereditary diseases
      in the family
Yes No
42. If yes, mention it.
43. If you have recently undergone a medical
      check-up pertaining to blood, urine, stool,
      sputum, any x-ray, ultrasonography, etc.,
      please mention the related reports.
44. Any other problem that you might like to
      state.
      

 
 
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