Kindly fill in the Consultation Form and help us understand the specifics of your physical, mental and spiritual aspects.

This will help our doctors in providing you with a personalized healthcare solution best suited to your needs.

Reimbursement and Cashless  TPA  Health Insurance  for the Process Of Kshar Sutra is available now.  In NCR,  Ghaziabad and Noida

Call us @ +91-9219434343,   9412637645

Whatsapp ::  +91-9412637645

 

   Consult Form

Download this form and Send us by Email us:  We would love to hear from you! Please fill out this form and and email us ::to  info@msarogyam.com  we will get in touch with you shortly.

Call us @ +91-9219434343,   9412637645, 

• Name*

your Full Name

• Email*

Your current active Email Address

• Phone Number*

Your current active no for contact.

• Profession

your profession

• Consultation for*
• Ano-Rectal
• Skin Disease
• Hair Disease
• Sexual Disease
• General Disease

Select the option any one, for more accuracy

• Address

Street AddressAddress Line 2City

State / Province / RegionZip / Postal Code

AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d’IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweCountry

Your complete address for Medicines etc

• Age*

your age

• Sex*
• Male
• Female

Your gender

• Weight*

your body weight eg: 58kg

• Blood Pressure*

your bp eg: 140/88

• Height*

your height in feet and inches eg: 5’9”

• Dependence on
• Alcohol
• Drugs
• Smoking
• Tobaco

select if any applicable .

• Are you a
• Vegetarian
• Non-vegetarian
• Chief Complaint*

 

What is your Main problem right now

• PAST MEDICAL HISTORY

 

If you have any past medical (disease) problem, describe, it and the medication for it, how long dose u took the medicine , any relief from medicine etc. if any

• Current Medication List

 

Current Medication List you are usingthe medicines you are using right now if any

• Allergies

 

Medication Allergies: _______________Food-Allergies:________________________Environmental Allergies: ____________________if any

• Social History

 

SOCIAL HISTORY:Single or MarriedOccupation: ________________________________Alcohol: _________ oz/day/weekAthletic Activities: _____________________________Tobacco: ____pks/d for ____ yrs____ if any

• Family History

 

FAMILY HISTORY: _____________________________________if any

• Female History*

 

Please Describe : First day of your last period.Length of cycles, length of period.Periods regularity, shortest and longest times.Severity increasing as time goes on.Spells of no periods in absence of pregnancy.Periods heavy, clots, flooding.Pads or tampons used, number required.Periods painful.Bleeding between periods, after intercourse. Time of menarche, menopause.If menopause: hot flushes, night sweats [assesses severity of decreasing estrogen].Bleeding before puberty, after menopause.

• Obstetric history

 

Obstetric historyPossibility of currently pregnant.Number of children, weights at birth.Number of times been pregnant [do math for miscarriages, terminations]: what month, why, how.Problems during gestation, delivery.Bleeding during pregnancy, ….if any

• Female Sexual history*

 

Sexual historySexually active.Number of partners.Contraception: on OCP? which one?Contraception: others currently using, used previously.Physical, other difficulties during intercourse.Pain during, after intercourse: deep/ superficial, always/ sometimes.Difficulty in conceiving.Pap smear: last smear’s date, result.

• Male Sexual History*

 

Male Sexual History ,About our Sexual Problem Describe with Deails

• Ano-Rectal History*
• Bleeding
• Burning During Defication
• Protrusion Of Mass

Select THE SYMPTOMS from the list

• Other Ano-Rectal Info

 

Please tell us about your current and past complications, or any other infor related to the Disease….if any…

• Urinary history*

 

Urinary historyColour change.Blood in urine.Frequency, amount changes.Pain, burning sensation.Feeling of incomplete emptying.Hesitancy, nocturia, dribbling.Incontinence, overflow incontinence, stress incontinence.

• Investigation Reports

 

Laboratory Investigation Reports (if any) :

• Brief hair loss history ?

 

Brief hair loss history ? How is the condition of your hair?

• Describe your hair problem & change your hair?

 

Describe your hair problem & change your hair?

• Have you had your hair coloured before?

 

Have you had your hair coloured before? describe if yes or any additional info

• Hair Type

StraightWavyCurly

• Hair Texture

FinNormalCoarse

• Hair Growth Patterns

CowslickWhirlDouble CrownWidows PeakIrregular NapeHair Growth Patterns

• Scalp Condition

NormalTightSensitiveDryFlaking

• How often do you shampoo your hair?

DailyEvery Other DayWeekly

• Which shampoo are you currently using?

• Do you use styling products?

GelMousseLotionCream

• How do you finish styling your hair?

Flat IronsTongsHeated RollersHot Brush

• Which product do you use to finish?

SprayWax / PommadeSerum / Gloss

• more concerns that you want your skin care

Fine lines & wrinklesEnlarged poresHyperpigmentationDry/flaky skinRedness/blotchinessOccasional acneRosaceaLoss of firmness/elasticityAge spotsPersistent acneDull skinSensitive skinother

• more concerns Describe other

 

• Shortly after you wash your face, how does your skin feel?

Tight or dryOily or shinyA combination of oily and dryNormal

• Choose one or more concerns you have about the skin around your eyes:

PuffinessDark circlesFine lines & wrinklesCreasesNone

• Last one! When you shop for skin and Hair care, do you prefer products that have natural and organic ingredients?

YesNo

• Other extra information

 

Other extra information which you think might be helpful….if any Please add any additional report etc.(i.e. jpg, gif, png, pdf) ….if anyAnd Your High Resolution Photo If you are Consulting for Skin ,Hair Allergy ,etc. you can email us the data @ info@msarogyam.com

• How did you hear about us?*

GoogleBingYahooFriend SuggestReturning CustomerOtherDetail about How did you hear about

 

That’s all……………………………………………

We would love to hear from you! Please fill out this form and and email us ::to  info@msarogyam.com  we will get in touch with you shortly.