|
How is you appetite
|
|
|
Do you have constipation?
|
Yes
No
|
|
Do you feel any burning sensation in chest/abdomen?
|
Yes
No
|
|
Type of food that you eat
|
Veg
Non-veg
|
|
Do you consume tobacco in any form?
|
Yes
No
|
|
Are you addicted to any other intoxicant(liquor/wine etc.)?
|
Yes
No
|
|
Do you suffer from sleeplessness?
|
Yes
No
|
|
Do you suffer from excessive urination?
|
Yes
No
|
|
Is your Urine colour yellowish?
|
Yes
No
|
|
Do you feel any irritation or burning sensation while passing urine?
|
Yes
No
|
|
How is your physique?
|
|
Are you a patient of Hypertension?
If yes, mention your blood pressure |
Yes
No
|
Are you diabetic?
If yes, mention the sugar level
In blood
In urine |
Yes
No
|
Have you suffered from any disease earlier?
If yes, name it |
Yes
No
|
|
Do you feel palpitation of heart or pain in the chest or breathlessness during physical exercise?
|
Yes
No
|
|
Any other problem that you might like to state
|
|
