Online Treatment Form
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SYMPTOMS OF PATIENT
Note: Interested Patient should fill up the form by clicking / Writing in the appropriate boxes given below and finally submit by clicking in the Submit button at the end.
Short description       of present diseases:
Appetite	Less  Excess  No Taste Hungry But Can't Eat  Normal
Thirst	Less  Excess  Mouth Dry But Without Thirst  Frequent But Little  Normal
Teeth Problem	Loose Bleeding Caries Pain      Blackish Eroded  Sensitive             Pyorrhea Normal
Eye/Nose/Throat	Sinus  Migraine  Chronic Headache Cold Susceptibility  Cataract  Cornial ulcer  Stye  Conjunctivitis  Glaucoma Nasal Polyp  Pharyngitis  Diphtheria  Ear discharge  Adenoid  Tonsillitis Nasal Polyp  Thyroid Problem  other ENT diseases
Stomach/Digestive System	Upset  Pain  Burning  Expectoration Sour Pungent Bitter   Sour  Salty   Gas   Acidity      Normal
Stool	Constipated Loose Mucus Paste Dysentery Blood Worm (thread/round/tape) Normal
Rectum (Piles/Anal Fissure/Fistula /Prolapse)	Bleeding Blind Ooze Pricking Pain Pus Itching Swelling No Pain Wet Internal Fistula External Fistula Normal
Heart/Chest	Pain Burning Congested Palpitation Cardiac Problem Blockage Stroke No problem
Lungs/Respiratory Diseases	Congestion Breathing No Problem Enlarged Spotted Cancer Chronic Cough  Asthma  Normal
Liver	Gas  Acidity  Indigestion  Dyspepsia  Enlarge  Jaundice viral hepatitis   Cirrhosis   No Problem
Gall Bladders	Pain Enlarged Pericardiatis Stone No Problem
Kidney	Pain  Enlarged  Congestion  Stone Uremia  Renal colic  Nephritis  Kidney Failure No problem
Urine	Burning Before Burning During Burning After Burning Always Diabetic Frequent Yellow Normal
Skin/Face/Acne	Borne Eruption Rash Eczema Dermatitis Scabies Allergy  Oedema Pimples   Urticaria Psoriasis Normal
Bone/Joint diseases	Arthritis  Osteoarthritis  Rheumatoid arthritis Osteoporosis  Lumber Pain  Back Pain (Lumbago)  Gout  Bone Pain  Bone Erosion  Bone Enlargement  Bone Tumor Spondylitis  Sciatica
Allergic/Urticaria To	Beef Prawn Sweet Gourd Hilsha Fish  Milk Egg Butter  Coconut Dust Pollen
Asthma	Yes    No    Previously Acute  Chronic  Dry  Wet  Loose
Blood Pressure	High     Low     Normal Systolic (if known)  Diastolic (if known)
Diabetis	Yes      No Blood sugar   Fasting   Random   2 hrs. ABF
Fever	Uninterrupted Flexible  Frequent Relapsed with Cough Relapsed with Headache Relapsed with Loose Motion
Headache	No   Yes At Day At Night At Sleep At Sun At Hungry Left Side Right Side
Cough	Yes    No
Female Diseases	Cyst Follicle Uterine Fibroid Tumor  Leucorrhoea  Menstruation problems  Abortion  Pregnancy problems  Miscarriage Infertility Cancer of Breast  Cancer of Cervix  Breast Tumor
Period/Means	Early Late Scanty Excess Blackish Irregular Long Lasting At Interval Normal
Uterus/Ovary	Cyst  Tumor  Abscess  Fibroid Cancer  Follicle  Enlarged   Normal
Leucorrhoea	Slight Excess Albumin Watery White Thick Thin Bad Smell Normal
Cyst/Abscess/Fibroid/ Wart/ Tumor/Lipoma (of mother)	Yes   No   Not known Blunt Big  Small  Soft  Hard Black pore Pulp inside Uterus  Ovary  Breast  Bone  Bellow skin
Male Sexual Problem	Weak   Quick Ejaculation   No Sexual Urge   Impotent  Retarded Normal
Cancer/Carcinoma	Uterus  Ovary  Breast  Blood  Liver  Throat  Brain  Stomach Other
Tumor	Yes  No Located at
Other Health Problems & other symptoms
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