Online Treatment Form
Name*
Gender*	Male     Female
Age*
Address*
City*		Zip/Post Code*
State		Country*
E-mail*
Phone
Fax
Marital Status	Unmarried Widow Divorced Married
Issues/Kids	Yes   No   Not Applicable
Configuration	Hight         Weight
Short description       of present diseases
Major Previous Diseases	Typhoid  TB     Syphilis  Gonorrhea Asthma   Piles   Jaundice
* Compulsory to fill up
SYMPTOMS OF PATIENT
Note: Interested Patient should fill up the form by clicking / Writing in the appropriate boxes given below and finally submit by clicking in the Submit button at the end.
Appetite	Less  Excess  No Taste Hungry But Can't Eat  Normal
Thirst	Less  Excess  Mouth Dry But Without Thirst  Frequent But Little  Normal
Teeth Problem	Loose Bleeding Caries Pain  Blackish Eroded  Sensitive to cold Pyorrhea Sensitive to Sour Sensitive to Sweet
Tongue Problem	White Coating  Blackish  Yellow Dry        Ulcerated     Pustules Cancer   Sore            Punch Like Sore
Eye Diseases	Cataract Sty  Tumor  Conjunctivitis Pus        Red  Dry     Watery Burning   Pain  Corneal Ulcer
Ear Diseases	Earache   Ear Discharge Watery   Pus Short of Hearing    Deafness Moist Oozing    Eczema Around  Roaring   Ringing Listen Better at Crowd Places
Nose Problem	Blockage   Polyp   Ulcerated  Reddish     Bent    Running Nose  No Secretion Sneezing Itching
Throat Problem	Tonsillit is: Left Right Both Sides Adenoid     Thyroid Enlarged  Loss of Voice   Gag   Tumor
Head Diseases	Vertigo Headache Eczema Dandruff Hair Loss  Alopecia Tumor Sinus Migraine
Headache	At Day  At Night  At Sleep  At Sun At Hungry  Left Side  Right Side Both Sides  Occasionally Always
Hair Diseases	Hair Loss  Dandruff Alopecia Early Graying  Poor Growth
Stomach Diseases	Upset  Pain  Burning  Expectoration Ulcer   Gas   Acidity Expectoration: Sour    Pungent    Bitter   Salty     Normal
Stool	Constipated    Loose   Mucus Paste   Dysentery   Blood Worm (thread/round/tape)   Normal
Rectum (Piles/Anal Fissure/Fistula /Prolapse/Polyp)	Piles    Anal Fissure     Fistula Rectal Prolapsed     Rectal polyp Bleeding   Non Bleeding     Ooze/Wet Pricking Pain    No Pain    Pus Itching      Swelling    Pain before Stool Pain after Stool    Internal Fistula External Fistula    Fistula Operated Before
Heart/Chest	Pain Burning Congested Palpitation Stroke: Once   Twice   More Cardiac Problem Blockage Stroke No problem S. Cholesterol:    S. HDL:             S. LDL:              Triglyceride (TG): ( Note: Only the patient having proven Heart Diseases should fill up the above blank Box)
Lungs Diseases / Respiratory Diseases	Congestion     Breathing Problem Enlarged     Spotted    Pleurisy Cancer    Chronic Cough    Asthma
Liver Diseases	Jaundice  Cirrhosis  Fatty Enlarged  Bitter Taste    Dyspepsia Blackish Tongue  Viral Hepatitis  bsAg + SGPT:        SGOT:        S. Billuribin   HBSAg Positive Yes   No ( Note: Only the patient having proven Liver Diseases, should fill up the above blank Boxes)
Gall Bladders	Pain   Enlarged  Pericardiatis Stone No Problem    No Pain Stone Operated Before
Kidney	Pain  Enlarged  Congestion  Stone Uremia  Renal colic  Nephritis  Kidney Failure Vacuities S.Creatinine
Urine	Burning Before  Burning During Burning After   Burning Always Diabetic      Frequent Urine Yellow     Normal    Redish
Skin/Face/Acne	Borne Eruption Rash Eczema Dermatitis Scabies Wart  Lipoma Black Spot   Urticaria Psoriasis White Spot/Vitiligo  Leucoderma
Bone/Joint diseases	Arthritis  Osteoarthritis  Rheumatoid arthritis Osteoporosis  Lumber Pain  Back Pain (Lumbago)  Gout  Bone Pain  Bone Erosion  Bone Enlargement  Bone Tumor Sodalities   Sciatica Pain   Back pain  Space Reduction Uric Acid:       S. Calcium:     S. Ige:           ( Note: Only the patient of proven Bone/Joint diseases, should fill up the above blank Boxes)
Allergic/Urticaria To	Beef Prawn Sweet Gourd Hilsha Fish  Milk Egg Butter  Coconut Dust Pollen
Asthma	Recent    Chronic     Severe Slight     Bronchial    Cardiac  Spasmodic  Allergic Low Blood Pressure Aggravate:   Morning   Night Winter   Summer   Rainy Season
Blood Pressure	High     Low     Normal Systolic (if known)  Diastolic (if known)
Diabetis /Blood Sugar	Excessive Thirsty  Excessive Appetite Body Jerking Palpitation Frequent Urine Fasting:       Random:      2Hrs. ABF:   ( Note: Only the patient with proven diabetic diseases should fill up the above blank Boxes)
Fever	Uninterrupted Flexible  Frequent Relapsed with Cough Relapsed with Headache  Relapsed with Loose Motion
Headache	At Day  At Night  At Sleep  At Sun At Hungry  Left Side Right Side Both Sides  Occasionally  Always
Cough /Cold	Acute Chronic  Dry Wet Loose Aggravate at: Morning Night Winter Rainy Season
Female Sex Diseases	Renal Colic  Gonorrhea No Sexual Urge Burning/Pain During Intercourse Leucorrhoea    Menstruation problems  Abortion       Pregnancy problems  Miscarriage Infertility Itching of Vagina Cancer of Cervix  Breast Tumor Ulceration of Vagina Other Problems:
Period/Means	Early Late Scanty Excess Blackish Irregular Long Lasting At Interval Normal
Uterus	Cyst  Tumor  Abscess  Fibroid Cancer  Follicle  Enlarged   Normal
Ovary	Cyst Tumor Abscess  Fibroid Cancer Follicle Enlarged Normal
Leucorrhoea	Slight Excess Albumin Watery White Thick Thin Bad Smell Normal
Cyst/Abscess/Fibroid/Wart/ Tumor/Lipoma (of mother)	Yes   No   Not known
Male Sexual Problem	Weak   Quick Ejaculation   No Sexual Urge   Impotent  Retarded Azospermia Oligospermia Sexually Weak Quick Ejaculation  Auto Ejaculation Nocturnal Pollution  Semen Out Before Urine  Semen out After Urine Semen Thin Discharge Prostrate Fluid Pain in Penis During Intercourse Poor Erection  No Erection  Masturbation Habit  Syphilis Hormone Deficiency Cutting Pain in Penis Normal Other Problems
Cancer/Carcinoma	Uterus  Ovary  Breast  Blood  Liver  Throat  Brain  Stomach Other
Tumor	Yes  No Located at
Other Health Problems & other symptoms
			Top