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Home E-Consultancy Female Form
E-Consultation for Female Patient
If you are a female and suffering from sexual or gynae related disease. Please Submit this form.

Name of the Patient
Age
Weight
Height
Profession
Marital Status
Email Address
Complete Postal Address
City
State/Province
Zip/Postal Code
Country
Date of marriage? (DD/MM/YYYY)
Number of children?
Age of youngest child e.g. 3 Yrs.5 Months
How is your physique?
Has there been any miscarriage?
If so, how many times?
Any child born after miscarriage?
Have you ever suffered form fainting or convulsive fits?
If so, was it-
Do you still get such fits?
Are the menstrual periods regular?
Are they painful?
Are you presently pregnant?
If yes, mention the date of last menses? (DD/MM/YYYY)
Do you feel any irritation or burning sensation while passing urine?
Is your Urine color yellowish?
Does any mucus (fluid/pus/white discharge) pass out in urine?
Are you having problem of white discharge (leucorrhoea) in particular?
Do you feel pain in the back?
Do you feel pain below the naval?
Do you have complaints of nausea or vomiting sensation in the morning?
How is you appetite?
Do you have constipation?
Do you feel any burning sensation in chest/abdomen?
Do you consume tobacco in any form?
Is there any history of hereditary disease in the family?
Mention it
Do you suffer or have you ever suffered from any venereal disease (Syphilis, Gonorrhea)?
Is your husband suffering or has ever suffered any venereal disease (Syphilis, Gonorrhea)?
If yes, indicate the exact nature of the disease
Are you diabetic?
If yes, mention sugar level in blood
in urine
Are you a patient of Hypertension?
If yes, mention your blood pressure e.g. 80/120
Important :
If you have recently undergone a medical check-up pertaining to Sputum, phlegm, blood, urine or any X-ray, please mention the related reports
Any other problem that you might like to state
 

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Shop  # B-13, Sector 14-B, K.D.A.
Flats Phase IV, Main Road Shadman
Town # 2., North Karachi 75850
KARACHI-PAKISTAN
Contact: +92-21-32029191
+92-333-3066980
Skype: Qureshi Health Care

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