Vaidya Consulting Vaidya Consulting Fields marked with an * are required Country * Select one Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia And Herzegowina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic Of The Cook Islands Costa Rica Cote D'Ivoire Croatia (Local Name: Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Timor-Leste (East Timor) Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard And Mc Donald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic Of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic Of Korea, Republic Of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia, Former Yugoslav Republic Of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Of Moldova, Republic Of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts And Nevis Saint Lucia Saint Vincent And The Grenadines Samoa San Marino Sao Tome And Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia, South Sandwich Islands Spain Sri Lanka St. Helena St. Pierre And Miquelon Sudan Suriname Svalbard And Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic Of Thailand Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis And Futuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe Height(c.m.) Weight(k.g.) Gender : * Select one Male Female Marital Status Select one Married Unmarried Postal Address With Contact Number(s) Diagnostic Details Present Complain Main Symptoms Health Problems Diabetes Mellitus High Blood Pressure Cancer ArthritusAsthmaAllergy Treatment Taken Result Obtained Select one Satisfactory Not Satisfactory Laboratory Investigation Details of Laboratory Investigation History of the disease You should give all details about the history of the disease including family history about the disease if any. You can mention all those symptoms which you feel are not the main symptoms, but bother you now and then. For Women Menstrual Cycle Select one Regular Irregular Menstruation for how many Days? Menstrual Bleeding : Select one Profuse Moderate Scanty Nature of Periods Select one Painful Painless Obestetric History How many childrens do u have? Any Operation, abortions or anything specific. Delivery Normal or Caesarian The time of the day when you usually go for evacuation Frequency Per Day Color of the stools Bowel Movements Consistency Select one Hard Solid Semisolid Watery Whether foul smelling Select one Yes No Do you tend to be constipated Select one Yes No Any other information you would like to share Urinary and other excretory systems Frequency of urine per day Quantity of Urine Less Adequate More Select one Color of the Urine Select one Normal Yellow Red Is there any burning sensation while passing urine Select one Yes No Any other information you would like to share Appetite & Digestion How is your appetite? Select one Normal Loss Excess Problems like heaviness, feeling weak & Lethargic immediately after eating? Select one Yes No Any pain in stomach area, specially after eating or empty stomach? : Select one Yes No If Yes Please Specify the area of pain Select one Upper Abdomen Lower Abdomen Liver Region Other Region Do you have wind or gas problem? Yes No Select one How are your eating habits? Regular Irregular Select one Do you have often acid formation, burning(with or without acid) or burning sensation? Yes No Select one Any other information you would like to share Diet Type? Veg Non-Veg Mixed Select one If Mixed how often you have Non Veg food in a week ? once Twice Everyday Other Select one Do you use spices? If Yes what kind and how much? Quantity of tea, Coffee, Milk or any other kind of drinks taken in a day? Quantity & Other(Specify) Tea Coffee Milk Other Select one How often do you eat fast food, fried foods frozen foods and foods that have been micro waved? Select one Daily Occasionally How much water do you usually drink in a day? Select one Less than 8-10 glass 8-10 glass more than 8-10 glass Exercise Exercise Select one Daily Occasionally None Type of Exercise? Select one Light Yoga Aerobics Heavy Are you obese/No Obese Select one Obese No Obese Habits Alcohol(Hard Drinks) Select one Yes No If Yes Quantity Soft Drinks Select one Yes No If Yes Quantity Smoking Select one Yes No If Yes Quantity Tobacco Select one yes no If Yes Quantity Betel Levees Select one Yes No If Yes Quantity Psychosomatic system What kind of mental nature do you have? Select one Quite Short Tempered Restless Others Others Please Specify Are you always in tension / anxiety / stress : Select one Yes No Is it related to some Select one Diet Activity Climate Other Others Please Specify
