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Enter Your Name

Age

Sex

Male

Female

Address

Phone

Email Address

Diet

Marital Status

Single

Married

Occupation

Language Spoken

Main complaint

Durations of complaint

Major Disease

Dibetic

Hypertension

Thyriod

Other

Already taking any treatment

Yes

No

Which type of medications

Allopathy

Homeopathy

Auyvada

Unani

Other

Associated symptoms with main complaint

How much thirst do you have

Do you feel any change in your taste and felling in your mouth

Do you have any problem about bowel movement …eg Constipation/loose motion/Gastritis/ other…

Yes

No

Any problem about Urine

Yes

No

Do you have any trouble before, during after passing urine

Yes

No

How much do you Sweet

Yes

No

Do you catch cough cold easily

Yes

No

Any nasal abnormality

Yes

No

Do you have Tonsillitis

Yes

No

Describe anything unusual about your sleep

Any sexual problem

Yes

No

Is there any difficulty in erection

Yes

No

Is there any premature ejaculations

Yes

No

For women Any dryness ,itching,discomfort,bleeding,burning or pain in vagina before,during or after sexual intercourse

Yes

No

Any pain in abdomen after intercourse

Yes

No

How are the menses …regular/irregular.

How many days is your monthly cycle

How is menstrual flow(days)

Quantity of flow..profuse/scanty/moderate

Do you have any complaints before,during or after menses

If menopausal ,mention the age of menopause

Is there any white discharge

Yes

No

If so mention the nature ,color,consistency and smell of discharge

Yes

No

Any itching,burning, due to discharge

Yes

No

Any trouble with breasts

Yes

No

Any other problem which not mention above Descripation

Do you suffer from weak erection,failing erection?