Strictly | गुप्त | Secret | Confidential
No one other than doctor can see your questions sent from here.
आप विस्तार से जानकारी देंगे तो आपको सही मार्गदर्शन/इलाज बताने में आसानी होगी।

Name *

Age *

Mother tounge

Gender *

E-mail *

Contact Number *

City

State

When and how did it begin?/ समस्या कैसे शुरू हुई? कब से है?

What treatment you have already taken and its result?/ आप ने क्या क्या इलाज किया

Do you have Diabetes/Hypertensioin/Heart Disease/Depression/Other illnesses? Which medicines are you taking?

According to you what is the cause of the problem?/ आप के अनुसार इस समस्या की क्या वजह है?

How many times in a week/month do you have sexual intercourse? /कीतने बार सेक्स करते हो (हप्ते मे/महिने मे/साल मे)?

Married

Yes No

Are you planning to get married

Yes No

What is your period cycle?

How many days are there in one cycle?

Are periods irregular or regular with variation of how many days?

Is it very irregular?

Yes No

Number of pregnancies

Number of abortions