Name* (Enter initial at last) ( i.e.Arul s) Address City State Country* List Of Countries 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 Herzegovina 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 Coco (Keeling Islands) Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire (Ivory Coast) Croatia (Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Island (Malvinas) Faroe Islands Fiji Finland France France (Metropolitan) French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Ghana Germany Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea (North) Korea (South) Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia 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 Seychelles Sierra Leone Singapore Slovak Republic Slovenia Solomon Islands Somalia South Africa S. Georgia and S. Sandwich Isls. Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States US Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Viet Nam Virgin Island (British) Virgin Island (US) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe Zip Code Telephone* Fax E mail General Health Condition Age Sex Male Female Marital Status --Select-- Married Unmarried Occupation Children Diabetic Yes No H.BP/L.BP Yes No High Cholesterol Yes No Nature of Work Field Office How many years Present Health Problems: Give full details Details about Motion and Urine Motion Daily Once Twise Soon after meals Many times Once in 2-3 days Nature Hard Semi Solid Watery Constipation Usual Occational After spicy food It is N.V. Meals Drug induced Motion Motion with Frequent Ocational Diarrhoea Urine Color Clear Dark Yellow Pale Yellow Turbid Deposits Sperms present Oily Dripping in Thread It is Easy Difficulty in passing very frequent Incontience It is Burning Pricking Pain Foul Smell Yes No No.of times H. Oil Use Yes No Oil Bath Yes No Meals Habit Veg Non - Veg Timely Untimely Poor Appetite Strong Normal Sleep Normal Distrubed On drug Sexual Activity - For men Organs Stiff Erection Normal No Erection Strong Weak Small and Contracted Masturbation Yes No No of years Intercourse No of Times (per week/ month) Infertility - for Women Menses Cycle Regular Irregular Flow for Days Bleeding With Cloths Without Cloths Colour Red Brown Black Stain on Cloths Yes No Foul Smell Yes No White Discharge Yes No Inflammation Yes No Pain Yes No Prolapse of the Uterus Yes No Spotting Yes No Menopause Age Laproscopy done Yes No Scanning Yes No Uterus Size Buiky Small Size Normal Size CMS Ovary Size Left Right Fallopian Tube Bloked - L R - Normal LMP Date Abortion Missed Abortion DNC Any illness with past six months Jaundice Typhoid Measels Any Surgery Migraine Fits TB Asthma Sneezing Sinusitis Family History Is this a Herditary Any Allergy - Food Medicine Other Diseases General Information Obese Anaemic Vericosity Filaria Physically Handicapped Pulse Condition B.P. Pulse Rate Clinical Test Test Date X- ray Scan Results, if any Details of treatments Previously taken Details Interested Research Membership Enrollment . Treatment advice with personal touch. Siddha rare Herbs
