Male case taking form

1
Name
First Name
Last Name
2
What is your main health concern?(Please describe in your own words. Example: acidity, hair fall, anxiety, joint pain, weakness, etc.)
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Ok
3
When did this problem start?Example: Since 3 months, after COVID, after marriage, after stress)
4
How did it begin?
Suddenly
Slowly over time
After illness (fever, dengue, COVID)
After emotional stress (breakup, loss, work pressure)
After injury
Don’t remember
5
What makes it worse?(Example: cold food, stress, walking, late nights, spicy food)
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Ok
6
What gives you relief or makes it better?(Example: rest, hot water, talking, sleep, medicines)
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Ok
7
Do you experience any other symptoms along with this?(Example: acidity with headache, fatigue with anxiety)
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Ok
8
How is your hunger/appetite?Single choice
Very good, frequent eating
Normal
Poor appetite
No hunger until late
Loss of hunger after stress
Excessive hunger during Stress
9
Food cravings or dislikes?Multiple choice
Craving sweets
Craving spicy/fried food
Salt / Salty
Craving sour (pickle, imli)
Craving cold drinks
Dislike milk
Dislike oily food
No specific cravings
Other
10
How is your thirst (water intake)?Single choice
Drinks a lot of water
Normal
Very less thirst
Dry mouth but avoids water
11
How are your bowel habits?Multiple choice
Regular
Constipation
Loose stools
Straining required
Incomplete feeling
Mucus or blood in stool
More motion in morning
Gets motion after tea/food
12
How's your Urination pattern?Multiple choice
Normal
Frequent urination
Burning during urination
Poor flow
Urge but can’t pass
Dribbling after urination
13
Do you sweat more or less?Multiple choice
Sweats normally
Sweats a lot (whole body)
Sweating on palms/soles
Smelly sweat
No sweating
Sweat Leaving stains
Other
14
How is your sleep?Multiple Choice
Sleeps well
Trouble falling asleep
Wakes up frequently
Nightmares
Sleeps but feels tired
Daytime drowsiness
15
Do you see any dreams repeatedly?(Any dreams that come again and again?)
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16
Are you sensitive to weather?Multiple choice
Can’t tolerate cold
Can’t tolerate heat
Skin issues in monsoon
Catch cold easily
Can’t tolerate extreme of both Hot & Cold
17
Are you sexually active?
Yes
No
Prefer not to say!
18
Any of these sexual issues?Multiple choice
Early ejaculation
Erection difficulty
Low libido
Nightfall
Pain during sex
Fear of sex
Can’t satisfy partner
Excess masturbation
Other
19
Kindly explain
20
How do you emotionally feel about your sexual life?(Example: Confident, anxious, guilty, disconnected, etc.)
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Ok
21
What is your usual mood like?
Calm
Irritable
Anxious
Angry
Sad
Moody
Overthinking
Emotionally numb
22
Which situations affect your emotions the most?
Being blamed
Failure/rejection
Pressure from family
Financial stress
Relationship conflict
Work overload
Being ignored
Childhood trauma
23
How do you react under stress?
Silent/withdrawn
Angry/shouting
Cry alone
Avoid everyone
Skip food or overeat
Overthink a lot
Feel suicidal
Other
24
How is your confidence?
Very confident
Okay, sometimes doubt myself
Lack confidence
Feel like a failure
25
Any emotional trauma from the past?(Breakup, abuse, bullying, betrayal, grief, humiliation, failure)
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26
In the list below, circle around names of ALL major illness so far suffered* This field is required.
TYPHOID
CHOLERA
FOOD POISONING
WORMS
MEASLES
CHICKEN POX
MUMPS
MALARIA
DENGUE
CHIKENGUNIYA
COVID
JAUNDICE
ANY LIVER OR GALL BLADDER RELATED DISEASE
RICKETS
RHEUMATISM/GOUT
BACKACHE
ANY SEXUALLY TRANSMITTED DISEASE
ANY HEART RELATED ISSUES
ANY KIDNEY RELATED ISSUES
ANY SURGERY DONE ( FOR EXAMPLE - TONSILS, APPENDIX, HERNIA, GALL STONES ETC )
TONSILITIS
SINUSITIS
BRONCHITIS
ADENOIDS
ASTHMA
TB / PLEURISY
ANY SERIOUS MENTAL UPSET
FITS OR CONVULSIONS
PARALYSIS
HEADACHES
MAJOR ACCIDENT
ANY SKIN DISEASE LIKE FUNGAL , URTICARIA , HERPES , ALLERY ETC
Other
27
TYPHOID Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
TYPHOID
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Homeopathy
Allopathy
Ayurveda
Other
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TYPHOID
At what age you suffered from it ?
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Duration
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Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
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28
CHOLERA Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
CHOLERA
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Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
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CHOLERA
At what age you suffered from it ?
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Duration
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Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
Row 0, Column 3
29
FOOD POISONING Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
FOOD POISONING
Row 0, Column 0
Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Row 0, Column 3
FOOD POISONING
At what age you suffered from it ?
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Duration
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Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
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30
WORMS Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
WORMS
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Homeopathy
Allopathy
Ayurveda
Other
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WORMS
At what age you suffered from it ?
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Duration
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Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
Row 0, Column 3
31
MEASLES Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
MEASLES
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Homeopathy
Allopathy
Ayurveda
Other
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MEASLES
At what age you suffered from it ?
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Duration
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Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
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32
CHICKEN POX Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
CHICKEN POX
Row 0, Column 0
Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Row 0, Column 3
CHICKEN POX
At what age you suffered from it ?
Row 0, Column 0
Duration
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Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
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33
MUMPS Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
MUMPS
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Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
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MUMPS
At what age you suffered from it ?
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Duration
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Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
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34
MALARIA Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
MALARIA
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Homeopathy
Allopathy
Ayurveda
Other
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MALARIA
At what age you suffered from it ?
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Duration
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Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
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35
DENGUE Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
DENGUE
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Homeopathy
Allopathy
Ayurveda
Other
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DENGUE
At what age you suffered from it ?
Row 0, Column 0
Duration
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Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
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36
CHIKENGUNIYA Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
CHIKENGUNIYA
Row 0, Column 0
Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Row 0, Column 3
CHIKENGUNIYA
At what age you suffered from it ?
Row 0, Column 0
Duration
Row 0, Column 1
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Are you facing any issues because of it today also?
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37
COVID Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
COVID
Row 0, Column 0
Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Row 0, Column 3
COVID
At what age you suffered from it ?
Row 0, Column 0
Duration
Row 0, Column 1
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
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38
JAUNDICE Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
JAUNDICE
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Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
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JAUNDICE
At what age you suffered from it ?
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Duration
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Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
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39
LIVER Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
Which disease
ANY LIVER OR GALL BLADDER RELATED ISSUES
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Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
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Row 0, Column 3
Row 0, Column 4
ANY LIVER OR GALL BLADDER RELATED ISSUES
At what age you suffered from it ?
Row 0, Column 0
Duration
Row 0, Column 1
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Are you facing any issues because of it today also?
Row 0, Column 3
Which disease
Row 0, Column 4
40
RICKETS Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
RICKETS
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Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
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Row 0, Column 3
RICKETS
At what age you suffered from it ?
Row 0, Column 0
Duration
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Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
Row 0, Column 3
41
GOUT Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
RHEUMATISM/GOUT
Row 0, Column 0
Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Row 0, Column 3
RHEUMATISM/GOUT
At what age you suffered from it ?
Row 0, Column 0
Duration
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Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
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42
BACKACHE Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
BACKACHE
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Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
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BACKACHE
At what age you suffered from it ?
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Duration
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Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
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43
SEX Provide details about
Which disease
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
ANY SEXUALLY TRANSMITTED DISEASE
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Row 0, Column 2
Homeopathy
Allopathy
Ayurveda
Other
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Row 0, Column 4
ANY SEXUALLY TRANSMITTED DISEASE
Which disease
Row 0, Column 0
At what age you suffered from it ?
Row 0, Column 1
Duration
Row 0, Column 2
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
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44
HEART Provide details about
Which disease
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
ANY HEART RELATED ISSUES
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Homeopathy
Allopathy
Ayurveda
Other
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Row 0, Column 4
ANY HEART RELATED ISSUES
Which disease
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At what age you suffered from it ?
Row 0, Column 1
Duration
Row 0, Column 2
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
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45
KIDNEY Provide details about
Which disease
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
ANY KIDNEY RELATED ISSUES
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Homeopathy
Allopathy
Ayurveda
Other
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Row 0, Column 4
ANY KIDNEY RELATED ISSUES
Which disease
Row 0, Column 0
At what age you suffered from it ?
Row 0, Column 1
Duration
Row 0, Column 2
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
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46
SURGERY Provide details about
Of Which body part
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
ANY SURGERY IS DONE
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Row 0, Column 1
Row 0, Column 2
Homeopathy
Allopathy
Ayurveda
Other
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ANY SURGERY IS DONE
Of Which body part
Row 0, Column 0
At what age you suffered from it ?
Row 0, Column 1
Duration
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Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
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47
TONSILITIS Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
TONSILITIS
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Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
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TONSILITIS
At what age you suffered from it ?
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Duration
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Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
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48
ADENOIDS Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
ADENOIDS
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Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
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ADENOIDS
At what age you suffered from it ?
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Duration
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Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
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49
SINUSITIS Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
SINUSITIS
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Homeopathy
Allopathy
Ayurveda
Other
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SINUSITIS
At what age you suffered from it ?
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Duration
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Treatment taken
Homeopathy
Allopathy
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Other
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Are you facing any issues because of it today also?
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50
BRONCHITIS Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
BRONCHITIS
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Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
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BRONCHITIS
At what age you suffered from it ?
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Duration
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Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
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51
ASTHMA Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
ASTHMA
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Homeopathy
Allopathy
Ayurveda
Other
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ASTHMA
At what age you suffered from it ?
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Duration
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Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
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52
TB Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
TUBERCULOSIS
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Homeopathy
Allopathy
Ayurveda
Other
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TUBERCULOSIS
At what age you suffered from it ?
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Duration
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Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
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53
MENTAL Provide details about
Which disease
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
ANY SERIOUS MENTAL UPSET
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Row 0, Column 1
Row 0, Column 2
Homeopathy
Allopathy
Ayurveda
Other
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Row 0, Column 4
ANY SERIOUS MENTAL UPSET
Which disease
Row 0, Column 0
At what age you suffered from it ?
Row 0, Column 1
Duration
Row 0, Column 2
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 3
Are you facing any issues because of it today also?
Row 0, Column 4
54
HEADACHE Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
CHRONIC HEADACHES
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Homeopathy
Allopathy
Ayurveda
Other
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CHRONIC HEADACHES
At what age you suffered from it ?
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Duration
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Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
Row 0, Column 3
55
FITS Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
FITS /CONVULSIONS
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Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
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FITS /CONVULSIONS
At what age you suffered from it ?
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Duration
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Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
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56
PARALYSIS Provide details about
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
Which part
PARALYSIS
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Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
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Row 0, Column 3
Row 0, Column 4
PARALYSIS
At what age you suffered from it ?
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Duration
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Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
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Are you facing any issues because of it today also?
Row 0, Column 3
Which part
Row 0, Column 4
57
ACCIDENT Provide details about
Which body part
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
ANY MAJOR ACCIDENT
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Row 0, Column 2
Homeopathy
Allopathy
Ayurveda
Other
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Row 0, Column 4
ANY MAJOR ACCIDENT
Which body part
Row 0, Column 0
At what age you suffered from it ?
Row 0, Column 1
Duration
Row 0, Column 2
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 3
Are you facing any issues because of it today also?
Row 0, Column 4
58
SKIN Provide details about
Which disease
At what age you suffered from it ?
Duration
Treatment taken
Are you facing any issues because of it today also?
ANY SKIN DISEASES LIKE ECZEMA, URTICARIA , ALLERGY ETC
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 3
Row 0, Column 4
ANY SKIN DISEASES LIKE ECZEMA, URTICARIA , ALLERGY ETC
Which disease
Row 0, Column 0
At what age you suffered from it ?
Row 0, Column 1
Duration
Row 0, Column 2
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 3
Are you facing any issues because of it today also?
Row 0, Column 4
59
In case we missed anything related to your PAST HEALTH ISSUES do let us know here
Huge
Large
Normal
Small
Ok
Ok
60
What all diseases did your PATERNAL GRAND FATHER suffer from?* This field is required.
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR DISEASE
Other
61
Provide details related to your PATERNAL GRANDFATHER'S diseases. Like age at which they suffer , what treatment they took etc.
62
What all diseases did your PATERNAL GRANDMOTHER suffer from?* This field is required.
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR DISEASE
Other
63
Provide details related to your PATERNAL GRANDMOTHER'S diseases. Like age at which they suffer , what treatment they took etc.
64
What all diseases did your MATERNAL GRANDFATHER suffer from?* This field is required.
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR DISEASE
Other
65
Provide details related to your MATERNAL GRANDFATHER'S diseases. Like age at which they suffer , what treatment they took etc.
66
What all diseases did your MATERNAL GRANDMOTHER suffer from?* This field is required.
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR DISEASE
Other
67
Provide details related to your MATERNAL GRANDMOTHER'S diseases. Like age at which they suffer , what treatment they took etc.
68
What all diseases did your FATHER suffer from?* This field is required.
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR DISEASE
Other
69
Provide details related to your FATHER'S diseases. Like age at which they suffer , what treatment they took etc.
70
What all diseases did your MOTHER suffer from?* This field is required.
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR DISEASE
Other
71
Provide details related to your MOTHER'S diseases. Like age at which they suffer , what treatment they took etc.
72
Anyone else in your family is suffering with any disease ?
BROTHER
SISTER
MATERNAL AUNT
MATERNAL UNCLE
PATERNAL AUNT
PATERNAL UNCLE
COUSIN SISTER
COUSIN BROTHER
OTHER
73
How many brothers do you have ?* This field is required.
0
1
2
3
4
5
74
What all diseases did your 1st BROTHER suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
Other
75
Provide details related to your 1st BROTHER'S diseases. Like age at which they suffer , what treatment they took etc.
76
What all diseases did your 2nd BROTHER suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
Other
77
Provide details related to your 2nd BROTHER'S diseases. Like age at which they suffer , what treatment they took etc.
78
What all diseases did your 3rd BROTHER suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
Other
79
Provide details related to your 3rd BROTHER'S diseases. Like age at which they suffer , what treatment they took etc.
80
What all diseases did your 4th BROTHER suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
Other
81
Provide details related to your 4th BROTHER'S diseases. Like age at which they suffer , what treatment they took etc.
82
What all diseases did your 5th BROTHER suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
Other
83
Provide details related to your 5th BROTHER'S diseases. Like age at which they suffer , what treatment they took etc.
84
How many sisters do you have ?* This field is required.
0
1
2
3
4
5
85
What all diseases did your 1st SISTER suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
Other
86
Provide details related to your 1st SISTER'S diseases. Like age at which they suffer , what treatment they took etc.
87
What all diseases did your 2nd SISTER suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
Other
88
Provide details related to your 2nd SISTER'S diseases. Like age at which they suffer , what treatment they took etc.
89
What all diseases did your 3rd SISTER suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
Other
90
Provide details related to your 3rd SISTER'S diseases. Like age at which they suffer , what treatment they took etc.
91
What all diseases did your 4th SISTER suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
Other
92
Provide details related to your 4th SISTER'S diseases. Like age at which they suffer , what treatment they took etc.
93
What all diseases did your 5th SISTER suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
Other
94
Provide details related to your 5th SISTER'S diseases. Like age at which they suffer , what treatment they took etc.
95
How many PATERNAL UNCLE do you have ?* This field is required.
0
1
2
3
4
5
96
What all diseases did your 1st PATERNAL UNCLE suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
97
Provide details related to your 1ST PATERNAL UNCLE'S diseases. Like age at which they suffer , what treatment they took etc.
98
What all diseases did your 2nd PATERNAL UNCLE suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
99
Provide details related to your 2ND PATERNAL UNCLE'S diseases. Like age at which they suffer , what treatment they took etc.
100
What all diseases did your 3rd PATERNAL UNCLE suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
101
Provide details related to your 3RD PATERNAL UNCLE'S diseases. Like age at which they suffer , what treatment they took etc.
102
What all diseases did your 4th PATERNAL UNCLE suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
103
Provide details related to your 4TH PATERNAL UNCLE'S diseases. Like age at which they suffer , what treatment they took etc.
104
What all diseases did your 5th PATERNAL UNCLE suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
105
Provide details related to your 5TH PATERNAL UNCLE'S diseases. Like age at which they suffer , what treatment they took etc.
106
How many PATERNAL AUNT do you have ?* This field is required.
0
1
2
3
4
5
107
What all diseases did your 1st PATERNAL AUNT suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
108
Provide details related to your 1st PATERNAL AUNT'S diseases. Like age at which they suffer , what treatment they took etc.
109
What all diseases did your 2nd PATERNAL AUNT suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
110
Provide details related to your 2nd PATERNAL AUNT'S diseases. Like age at which they suffer , what treatment they took etc.
111
What all diseases did your 3rd PATERNAL AUNT suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
112
Provide details related to your 3rd PATERNAL AUNT'S diseases. Like age at which they suffer , what treatment they took etc.
113
What all diseases did your 4th PATERNAL AUNT suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
114
Provide details related to your 4th PATERNAL AUNT'S diseases. Like age at which they suffer , what treatment they took etc.
115
What all diseases did your 5th PATERNAL AUNT suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
116
Provide details related to your 5th PATERNAL AUNT'S diseases. Like age at which they suffer , what treatment they took etc.
117
How many MATERNAL AUNT do you have ?* This field is required.
0
1
2
3
4
5
118
What all diseases did your 1st MATERNAL AUNT suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
119
Provide details related to your 1st MATERNAL AUNT'S diseases. Like age at which they suffer , what treatment they took etc.
120
What all diseases did your 2nd MATERNAL AUNT suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
121
Provide details related to your 2nd MATERNAL AUNT'S diseases. Like age at which they suffer , what treatment they took etc.
122
What all diseases did your 3rd MATERNAL AUNT suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
123
Provide details related to your 3rd MATERNAL AUNT'S diseases. Like age at which they suffer , what treatment they took etc.
124
What all diseases did your 4th MATERNAL AUNT suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
125
Provide details related to your 4th MATERNAL AUNT'S diseases. Like age at which they suffer , what treatment they took etc.
126
What all diseases did your 5th MATERNAL AUNT suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
127
Provide details related to your 5th MATERNAL AUNT'S diseases. Like age at which they suffer , what treatment they took etc.
128
How many MATERNAL UNCLE do you have ?* This field is required.
0
1
2
3
4
5
129
What all diseases did your 1st MATERNAL UNCLE suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
130
Provide details related to your 1st MATERNAL UNCLE'S diseases. Like age at which they suffer , what treatment they took etc.
131
What all diseases did your 2nd MATERNAL UNCLE suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
132
Provide details related to your 2nd MATERNAL UNCLE'S diseases. Like age at which they suffer , what treatment they took etc.
133
What all diseases did your 3rd MATERNAL UNCLE suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
134
Provide details related to your 3rd MATERNAL UNCLE'S diseases. Like age at which they suffer , what treatment they took etc.
135
What all diseases did your 4th MATERNAL UNCLE suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
136
Provide details related to your 4th MATERNAL UNCLE'S diseases. Like age at which they suffer , what treatment they took etc.
137
What all diseases did your 5th MATERNAL UNCLE suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
138
Provide details related to your 5th MATERNAL UNCLE'S diseases. Like age at which they suffer , what treatment they took etc.
139
How many COUSIN BROTHER do you have ?* This field is required.
0
1
2
3
4
5
140
What all diseases did your 1st COUSIN BROTHER suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
141
Provide details related to your 1st COUSIN BROTHER'S diseases. Like age at which they suffer , what treatment they took etc.
142
What all diseases did your 2nd COUSIN BROTHER suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
143
Provide details related to your 2nd COUSIN BROTHER'S diseases. Like age at which they suffer , what treatment they took etc.
144
What all diseases did your 3rd COUSIN BROTHER suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
145
Provide details related to your 3rd COUSIN BROTHER'S diseases. Like age at which they suffer , what treatment they took etc.
146
What all diseases did your 4th COUSIN BROTHER suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
147
Provide details related to your 4th COUSIN BROTHER'S diseases. Like age at which they suffer , what treatment they took etc.
148
What all diseases did your 5th COUSIN BROTHER suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
149
Provide details related to your 5th COUSIN BROTHER'S diseases. Like age at which they suffer , what treatment they took etc.
150
How many COUSIN SISTER do you have ?* This field is required.
0
1
2
3
4
5
151
What all diseases did your 1st COUSIN SISTER suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
152
Provide details related to your 1st COUSIN SISTER'S diseases. Like age at which they suffer , what treatment they took etc.
153
What all diseases did your 2nd COUSIN SISTER suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
154
Provide details related to your 2nd COUSIN SISTER'S diseases. Like age at which they suffer , what treatment they took etc.
155
What all diseases did your 3rd COUSIN SISTER suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
156
Provide details related to your 3rd COUSIN SISTER'S diseases. Like age at which they suffer , what treatment they took etc.
157
What all diseases did your 4th COUSIN SISTER suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
158
Provide details related to your 4th COUSIN SISTER'S diseases. Like age at which they suffer , what treatment they took etc.
159
What all diseases did your 5th COUSIN SISTER suffer from?
CANCER
DIABETES
TUBERCULOSIS
HYPERTENSION
HEART TROUBLE
KIDNEY DISEASE
LIVER DISEASE
LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
160
Provide details related to your 5th COUSIN SISTER'S diseases. Like age at which they suffer , what treatment they took etc.
161
In case we missed anything related to your FAMILY'S HEALTH ISSUES do let us know here
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Large
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Ok
162
Are you taking any regular medicines?
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Ok
Ok
163
What is your daily routine like (job + home)?
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Ok
Ok
164
Any addictions or repeated habits?
Tea/coffee (3+ cups)
Smoking
Alcohol
Tobacco/Gutkha
Pornography
Excess mobile
Masturbation
Emotional eating
None
165
Do you do any physical activity/exercise?
Yes – Regularly
Sometimes
No
166
What type?
167
How would you rate your stress level?
Low
Medium
High
Very High
168
Do you feel life is like a competition or fight?
Yes – I have to prove myself
Yes – I feel dominated/suppressed
No – I don’t feel that way
Other
169
In a group, how do you behave?
Like to lead
Try to fit in
Feel ignored
Want to be praised
Prefer to stay alone
170
Are you very sensitive — to people’s words, food, weather, emotions?
Yes
Somewhat
No
Other
171
Do you think in steps/phases like “I must grow, achieve stage-by-stage”?
Yes
No
I don’t know
Other
172
Do you carry guilt, trauma, or feel broken emotionally or physically?
Yes
No
Other
173
Do you wish to explain more.
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Ok
174
Do you feel disconnected from your energy or vitality (tired, flat, joyless)?
Yes
No
Other
175
Kindly describe more.
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Small
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Ok
Should be Empty: