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Theraputic Form
Select the disease (*)
Psoriasis package include
Paralysis
Neurological ailments
Infertility
Impotency
Spine problems
Skin diocese & psychosomatic disorders
Anxiety
Bronchitis & asthma
Conjunctivitis
Back pain
Frozen Shoulder
Shoulder pain
Diabetes mellitus
High blood presser
Gastritis
Constipation
Common cough and could
Colitis inflammation of the bladder
Cataract
Cervical spondylosis
OTHER DISEASES
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Email (*)
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Name (*)
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Country of residence (*)
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Sex (*)
Male
Female
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Nature of job (Press "CTRL" key to multiple selection)) (*)
Duration of sitting is long
Duration of standing is long
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Details of disease conditions you are suffering
Time period (*)
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Other informations
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Categorization of pain (*)
Not disturb for day to day activities.
Daily activities can be performed when get pain killers.
Difficult to perform even with pain killers.
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Describe the causes of disease and why it becomes serious (*)
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Previous disease conditions?
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What are the surgeries you have been undergone
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Your food habits
(It is important to mention the content of food, if you are aware about that. eg : bun, wheat flour)
What you had for your breakfast (*)
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What you had for your lunch (*)
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What you had for your dinner (*)
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Do you have any food allergies (*)
Yes
No
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Select the tastes as your preference
Sweet taste
Acid taste
Salt taste
Bitter taste
Pungent taste
Decoction taste
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Life style
When you go to bed (*)
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When you wakeup (*)
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Do you have a continous sleeping (*)
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What do you do for exercises and duration (*)
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Addictins and habits (*)
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Do you take alcohol frequently
Yes
No
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Amount you take per day
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Do you smoke
Yes
No
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Height (*)
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Weight (*)
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Size arround your belly (*)
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Do you have hereditary diseases (*)
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Does your family have hereditary diseases (*)
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Number of times you urinate
Day (*)
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Night (*)
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Color of urine (*)
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Are there any smell of urine (*)
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Number of times you stool
Appetite (*)
Very frequently getting hungry
I am getting hungry at the 3 main meals
I eat at same time of the day even if i am not hungry
I feel hungry, but i can't eat
I have good appetite and can eat more food
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Day (*)
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Only for Female
Night (*)
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Age of puberty (*)
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Nature of stool
High density
Normal
Low density
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Do you have a regular menstrual circle from the day of puberty (*)
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How often menses is happened (*)
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How many days menstrual period exists (*)
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Do you have any pain at menses (*)
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Describe the nature of the pain
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Nature of menstrual blood
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Number of pregnancies
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Number of children
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Number of Gastronomy
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Attach your reports as a Zip file
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Please enter these numbers
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