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Online Health checkup form
Home
Online Diagnosis
Personal Details
You Complete Name
Religion
Marital Status
Please Select
Married
Unmarried
Occupation
Other
Retail Worker
Architect
Administrative Assistant
Real Estate Agent
Bartender
Financial Analyst
Marketing Specialist
Healthcare Assistant/Aide
Photographer/Videographer
Writer/Journalist
Scientist/Researcher
Artist/Designer
Driver (various types)
Mechanic
Plumber
Electrician
Chef/Cook
Lawyer
Police Officer
Farmer
Construction Worker
Engineer (various fields)
Manager/Administrator
Customer Service Representative
Salesperson
Accountant
Software Developer/Engineer
Nurse
Doctor/Physician
Teacher/Educator
City
State/Province
Country
Geographical Area Land
---------
Dry land
Wetland/Marshy land
Normal land
Mobile Number
Email
Bodily Measurements
Weight (kg)
Height (cms)
General Elements
Main Complaints
(Also mention since how long have you been experiencing)
Previous Illness History
Surgical History
Medicine History
Family History
Routine
Wake Up
---------
Before Sunrise
After Sunrise
Appetite
---------
Good Appetite
No feeling of Appetite
Some Times Good Some Times No Feeling of Appetite
Meal Timing
---------
Regular
Irregular
Only After Feeling of Appetite
Scheduled as per Timing
Breakfast
---------
Yes
No
Sometimes
Breakfast Timing
---------
Morning
Evening
Both Times
None
Lunch Timing
---------
Before 10.00 AM
10.00 AM - 11.00 AM
11.00 AM - 12.00 PM
12.00 PM - 02.00 PM
After 02.00 PM
Dinner Timing
---------
Before Sunset
07.00 PM - 08.00 PM
08.00 PM - 09.00 PM
09.00 PM - 10.00 PM
10.00 PM - 11.00 PM
After 11.00 PM
Very Irregular
Avaragly Consumed Food Items
Goundnuts
Nonveg
Raw Food (Uncooked Food)
Fasting (Langhan / Upvaas)
Sago (Saabudaanaa)
Milk Products
Stale Food (Baansi Cheeze)
Bhel / Panipuri / Ragada pattis etc.
Gram Food (Besan Atta Foods)
Fermented Food (Idli/ Dosa/Uttapa etc.)
Misal / Vada-paav / Samosa / Kachori etc.
Bakery Products
Sprouted Food
Fried Food
Poha
Flakes
Papad
Pickle
Curd
Chinese
Hotelling
Paryushit anna
Max Consumption
(Which types of taste you eat maximum)
---------
Sweet Food
Sour Food
Salty Food
Bitter Food
Pungent Food
Stringent Food
Water with Meal (in liters)
Tea Habit
Viruddha Anna
Drinking cold water immediately after consuming hot beverages
Consuming pungent and bitter foods at the beginning of meals
Consuming sweets after finishing meals
Consuming curd during the night
Consuming heated honey
Consuming coffee or tea with breakfast items
Consuming breakfast items with milk
Consuming milkshakes with meals or as snacks
Consuming fruits with milk
Consuming fish with milk
Mixing raw and cooked foods in the same meal
Consuming salad with meals
Consuming curd with meals
Consuming milk with meals
Exercise
---------
Daily
Sometimes
Never
Type of Job
Emergency Services Jobs
Freelance Jobs
Retail Jobs
Priest/Clergy Jobs
AC Office Jobs
Logistics Jobs
Educational Jobs
Healthcare Jobs
Artisan/Craft Jobs
Analytical Jobs
Hands-on Jobs
Administrative Jobs
Service Jobs
Outdoor Jobs
Remote Jobs
Management Jobs
Customer-facing Jobs
Technical Jobs
Creative Jobs
Manual Labor Jobs
Travel Jobs
Desk Jobs
Field Jobs
Standing Jobs
Sitting Jobs
Bad Habits
Drinking colddrinks excessively
Overuse of painkillers or other medication without doctor's advice
junk food
Consuming too much sugar
Overeating
Mobile Game Addict
Musterbation
Pornography
Use of Masheri
Alcohol
Gutkha
Tobacco Chewing
Cigarette
Coffee
Not Any
Mood
---------
Normal
Anxiety
Depression
Irritability
Euphoria
Obsession
Neurosis
Depersonalization
Sexual Habit
---------
Daily
Alternate Day
Twice a Week
Once a Week
Once in a Month
Once in Two Months
Once in Three Months
Quarterly
Once in Six Months
Once in a Year
Never
Stress Level
---------
No Stress
Very Low
Low
Moderate
High
Very High
Sleep Quality
---------
Sound sleep in Night
Breaking Sleep
More Dreams
Afternoon Sleep
---------
Yes
No
Sometimes
Jagaran / Awake at Night
---------
Yes
No
Sometimes
Life Orientation
Other
Experimental
Traditional
Skeptical
Adaptable
Epicurean
Eclectic
Nihilistic
Empathetic
Driven
Reflective
Grounded
Open-minded
Curious
Resilient
Grateful
Balanced
Stoic
Adventurous
Content
Ambitious
Idealistic
Pragmatic
Spiritual
Cynical
Hopeful
Realistic
Pessimistic
Optimistic
Ashtvid Parikshna
Nadi / Pulse
Bowel Habits
Do you need Tea / Coffee / other things for Sensation
Do you have feeling of Defecation
Do you visit Toilet Daily
Stool Nature
With Blood
Geenish
Brownish
Dark Yellowish
Yellowish
Sticky
Watery
Semisolid
Solid
Urine Frequency
---------
2-3 times in 24 Hrs.
4-6 times in 24 Hrs.
More than 6 times in 24 Hrs.
More in Day Time & Not During Night
Sometimes during Night Also
Always during Night Also
Sweating
---------
Continuous sweating Round the Year
Only in Summer
More Than Others
Just After Physical Work
Profuse with Smell
Stains Cloths
More on Palms
Tongue
---------
Coated
Uncoated
Partially Coated
Tongue Color
---------
Whitish
Pinkish
Blackish
Voice
---------
Normal
Low Pitch
High Pitch
Hoarse
Breathy
Nasal
Monotone
Slurred
Stuttered
Weak
Fast
Slow
Hesitant
Halting
Garbled
Breath Smell
---------
Good Breath
Halitosis
Morning Breath
Food Odor
Dry Mouth Odor
Tobacco Breath
Alcohol Breath
Ketosis (Fruity or Acetone) Breath
Gastrointestinal Odor
Sinusitis Odor
Tonsil Stones
Oral Infections
Touch Sensation
---------
Hot
Warm
Normal
Cool
Cold
Dry
Soft
Eye Size
---------
Small
Medium
Large
Sclera Color
---------
White
Blue
Gray
Green
Yellow
Brown
Red
Black
Gynecologal complaints for femals only
Menstrual Cycle Period
---------
Less than 1 day
1 day
2 days
3 days
4 days
5 days
6 days
More than 7 days
Menstrual Cycle
---------
Less than 15 days
15 to 20 days
21 to 25 days
26 to 28 days
29 to 30 days
31 to 35 days
More than 35 days
Menstrual Bleeding
---------
Scanty
Moderate
Excessive
Menstrual Complaints
None
Obstetric History
None
Abortion/Miscarriage History
Yes
No
Medical Reports
Upload available reports like Blood, USG, MRI, CT, X-ray, etc (You can upload multiple files)
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