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Health History Form
Please give all the possible details about your ailment.
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Enter Payment Transaction ID *
Your Name *
Email *
Address
Age
Height
Weight
Occupation
Constitution-Points-Vata:
Total of Vata points from your Prakruti determination form
Constitution-Points-pitta:
Total of Pitta points from your Prakruti determination form
Constitution-Points-Kapha:
Total of Kapha points in your Prakruti determination form
Gender
Male
Female
Additional Information for women
Marital Status
Number of children
Menstrual Periods
Regular
Irregular
Bleeding For Days
3
4
5
6
more
Bleeding
Scanty
Normal
Excessive
Pain
Severe pain more than 1 day
Moderate pain 1 day
No pain
Oral Contraceptive
Yes
No
Physical like Intrauterine devices
Vaginal Discharge
Yes
No
Color Of Discharge
Egg yolk like
Yellow with foul smell + itching
Thick whitish
