First Name* Last Name* Your Email* Nationality* Address Country* Phone Mobile* Age* Gender: Male Female Marital Status: Married Single Weight Blood Pressure Are you a Vegetarian: Yes NO Height Present Health Problems* Dependence on: Alcohol Drugs Smoking Coffee/Tea Other Substances/Medication Any Previous Investigations Report Any Past History: Hypertension (high B.P.) Diabetes Allergy Surgery Others Pregnant/Lactation Other information which you think might be helpful Main Complaint Planning for Pregnancy in next 6 Months: Yes NO Any other associated minor Complaints Duration of the complaint: Functional history: Appetite Acidity Gas Motion Urination – day/night Sleep – day/night Diet - veg/non veg Lifestyle – daily general routine Others Taking any Medication at present Blood group: Photo: Submit
