Ask The Expert Ask Expert Name Age (Yrs.) Profession Weight (Kg.) Height (e.g. 5 feet, 7 inches.) Sex Please Select Male Female Marital Status Please Select Married Unmarried Email Mobile Number Complete Postal Address 1. Describe your main problems for which you want to seek our advice. 2. For how long, are you suffering from these problems ? 3. How is your physique ? Fat Slim 4. How is your appetite ? Good Poor 5. Do you have constipation ? Yes No 6. Type of food that you eat. Veg. Non-Veg. 7. Do you consume tobacco in any form ? Yes No 8. Are you addicted to any other intoxicant (e.g., liquor/wine etc.) ? Yes No 9. Do you take excessive quantity of tea or coffee ? Yes No 10. Do you suffer from sleeplessness ? Yes No 11. Do you suffer from excessive urination ? Yes No 12. Do you feel any irritation or burning sensation while passing urine ? Yes No 13. Do you feel palpitation of heart or pain in chest or breathlessness during physical exercise ? Smooth Restricted 14. Are you a patient of High Blood Pressure ? Yes No 15. If yes, mention your blood pressure. Systolic / Diastolic 16. Are you suffering from Diabetes ? Yes No 17. If yes, mention Blood Sugar Fasting PP Random 18. Have you suffered from any disease earlier ? Yes No 19. If yes, Name it. 20. If you have recently undergone a medical check-up pertaining to blood, urine, stool, sputum, any x-ray / ultrasonography, please mention the related reports. 21. Any other problem that you might like to state. 22. Is there a history of any hereditary disease in the family ? Systolic / Diastolic 23. If yes, mention it.