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Male case taking form - AK
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1
Name
First Name
Last Name
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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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When did this problem start?
Example: Since 3 months, after COVID, after marriage, after stress)
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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
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What makes it worse?
(Example: cold food, stress, walking, late nights, spicy food)
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What gives you relief or makes it better?
(Example: rest, hot water, talking, sleep, medicines)
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Do you experience any other symptoms along with this?
(Example: acidity with headache, fatigue with anxiety)
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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
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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
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10
How is your thirst (water intake)?
Single choice
Drinks a lot of water
Normal
Very less thirst
Dry mouth but avoids water
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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
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12
How's your Urination pattern?
Multiple choice
Normal
Frequent urination
Burning during urination
Poor flow
Urge but can’t pass
Dribbling after urination
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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
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14
How is your sleep?
Multiple Choice
Sleeps well
Trouble falling asleep
Wakes up frequently
Nightmares
Sleeps but feels tired
Daytime drowsiness
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15
Do you see any dreams repeatedly?
(Any dreams that come again and again?)
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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
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17
Are you sexually active?
Yes
No
Prefer not to say!
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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
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19
Kindly explain
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20
How do you emotionally feel about your sexual life?
(Example: Confident, anxious, guilty, disconnected, etc.)
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21
What is your usual mood like?
Calm
Irritable
Anxious
Angry
Sad
Moody
Overthinking
Emotionally numb
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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
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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
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24
How is your confidence?
Very confident
Okay, sometimes doubt myself
Lack confidence
Feel like a failure
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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
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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
Homeopathy
Allopathy
Ayurveda
Other
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TYPHOID
At what age you suffered from it ?
Row 0, Column 0
Duration
Row 0, Column 1
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Are you facing any issues because of it today also?
Row 0, Column 3
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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
Row 0, Column 0
Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
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CHOLERA
At what age you suffered from it ?
Row 0, Column 0
Duration
Row 0, Column 1
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Are you facing any issues because of it today also?
Row 0, Column 3
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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
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Row 0, Column 3
FOOD POISONING
At what age you suffered from it ?
Row 0, Column 0
Duration
Row 0, Column 1
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Are you facing any issues because of it today also?
Row 0, Column 3
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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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Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
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WORMS
At what age you suffered from it ?
Row 0, Column 0
Duration
Row 0, Column 1
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Are you facing any issues because of it today also?
Row 0, Column 3
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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
Homeopathy
Allopathy
Ayurveda
Other
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MEASLES
At what age you suffered from it ?
Row 0, Column 0
Duration
Row 0, Column 1
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
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Row 0, Column 3
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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
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
Row 0, Column 1
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Are you facing any issues because of it today also?
Row 0, Column 3
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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
Homeopathy
Allopathy
Ayurveda
Other
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Row 0, Column 3
MUMPS
At what age you suffered from it ?
Row 0, Column 0
Duration
Row 0, Column 1
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Are you facing any issues because of it today also?
Row 0, Column 3
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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
Row 0, Column 0
Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
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MALARIA
At what age you suffered from it ?
Row 0, Column 0
Duration
Row 0, Column 1
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Are you facing any issues because of it today also?
Row 0, Column 3
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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
Row 0, Column 0
Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Row 0, Column 3
DENGUE
At what age you suffered from it ?
Row 0, Column 0
Duration
Row 0, Column 1
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Are you facing any issues because of it today also?
Row 0, Column 3
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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
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
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Are you facing any issues because of it today also?
Row 0, Column 3
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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
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
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Are you facing any issues because of it today also?
Row 0, Column 3
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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
Row 0, Column 0
Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
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Row 0, Column 3
JAUNDICE
At what age you suffered from it ?
Row 0, Column 0
Duration
Row 0, Column 1
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Are you facing any issues because of it today also?
Row 0, Column 3
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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
Row 0, Column 0
Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
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
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
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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
Row 0, Column 0
Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Row 0, Column 3
RICKETS
At what age you suffered from it ?
Row 0, Column 0
Duration
Row 0, Column 1
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Are you facing any issues because of it today also?
Row 0, Column 3
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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
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
Row 0, Column 1
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Are you facing any issues because of it today also?
Row 0, Column 3
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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
Row 0, Column 0
Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Row 0, Column 3
BACKACHE
At what age you suffered from it ?
Row 0, Column 0
Duration
Row 0, Column 1
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Are you facing any issues because of it today also?
Row 0, Column 3
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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
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 3
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
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 3
Are you facing any issues because of it today also?
Row 0, Column 4
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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
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 3
Row 0, Column 4
ANY HEART 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
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 3
Are you facing any issues because of it today also?
Row 0, Column 4
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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
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 3
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
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 3
Are you facing any issues because of it today also?
Row 0, Column 4
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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
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 3
Row 0, Column 4
ANY SURGERY IS DONE
Of 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
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 3
Are you facing any issues because of it today also?
Row 0, Column 4
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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
Row 0, Column 0
Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Row 0, Column 3
TONSILITIS
At what age you suffered from it ?
Row 0, Column 0
Duration
Row 0, Column 1
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Are you facing any issues because of it today also?
Row 0, Column 3
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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
Row 0, Column 0
Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Row 0, Column 3
ADENOIDS
At what age you suffered from it ?
Row 0, Column 0
Duration
Row 0, Column 1
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Are you facing any issues because of it today also?
Row 0, Column 3
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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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Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
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SINUSITIS
At what age you suffered from it ?
Row 0, Column 0
Duration
Row 0, Column 1
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Are you facing any issues because of it today also?
Row 0, Column 3
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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
Row 0, Column 0
Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Row 0, Column 3
BRONCHITIS
At what age you suffered from it ?
Row 0, Column 0
Duration
Row 0, Column 1
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Are you facing any issues because of it today also?
Row 0, Column 3
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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
Row 0, Column 0
Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Row 0, Column 3
ASTHMA
At what age you suffered from it ?
Row 0, Column 0
Duration
Row 0, Column 1
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Are you facing any issues because of it today also?
Row 0, Column 3
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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
Row 0, Column 0
Row 0, Column 1
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
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TUBERCULOSIS
At what age you suffered from it ?
Row 0, Column 0
Duration
Row 0, Column 1
Treatment taken
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 2
Are you facing any issues because of it today also?
Row 0, Column 3
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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
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Homeopathy
Allopathy
Ayurveda
Other
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 3
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
Homeopathy
Allopathy
Ayurveda
Other
Row 0, Column 3
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ACCIDENT Provide details about
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LUNG DISEASES
SKIN DISEASES
MENTAL ISSUES
NO MAJOR ILLNESS
Other
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145
Provide details related to your 3rd COUSIN BROTHER'S diseases. Like age at which they suffer , what treatment they took etc.
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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
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147
Provide details related to your 4th COUSIN BROTHER'S diseases. Like age at which they suffer , what treatment they took etc.
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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
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149
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150
How many COUSIN SISTER do you have ?
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1
2
3
4
5
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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
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152
Provide details related to your 1st COUSIN SISTER'S diseases. Like age at which they suffer , what treatment they took etc.
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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
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154
Provide details related to your 2nd COUSIN SISTER'S diseases. Like age at which they suffer , what treatment they took etc.
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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
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156
Provide details related to your 3rd COUSIN SISTER'S diseases. Like age at which they suffer , what treatment they took etc.
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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
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158
Provide details related to your 4th COUSIN SISTER'S diseases. Like age at which they suffer , what treatment they took etc.
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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
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160
Provide details related to your 5th COUSIN SISTER'S diseases. Like age at which they suffer , what treatment they took etc.
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161
In case we missed anything related to your FAMILY'S HEALTH ISSUES do let us know here
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162
Are you taking any regular medicines?
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163
What is your daily routine like (job + home)?
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164
Any addictions or repeated habits?
Tea/coffee (3+ cups)
Smoking
Alcohol
Tobacco/Gutkha
Pornography
Excess mobile
Masturbation
Emotional eating
None
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165
Do you do any physical activity/exercise?
Yes – Regularly
Sometimes
No
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166
What type?
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167
How would you rate your stress level?
Low
Medium
High
Very High
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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
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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
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170
Are you very sensitive — to people’s words, food, weather, emotions?
Yes
Somewhat
No
Other
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171
Do you think in steps/phases like “I must grow, achieve stage-by-stage”?
Yes
No
I don’t know
Other
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172
Do you carry guilt, trauma, or feel broken emotionally or physically?
Yes
No
Other
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173
Do you wish to explain more.
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174
Do you feel disconnected from your energy or vitality (tired, flat, joyless)?
Yes
No
Other
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175
Kindly describe more.
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Male case taking form - AK
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