World Best Treatment
Name of patient
Complete Postal Address
Describe your main problems for which you want to seek our advice
For how long, are you suffring from these problems?
How your physique?
How is your appetite ?
Do you have constipation ?
Type of food that you eat.
Do you consume tobacco in any form ?
Are you addicted to any other intoxicant (e.g., liquor/wine etc.) ?
Do you take excessive quantity of tea or coffee ?
Do you suffer from sleeplessness ?
Do you suffer from excessive urination ?
Do you feel any irritation or burning sensation while passing urine ?
Do you feel palpitation of heart or pain in chest or breathlessness during physical exercise ?
Are you a patient of High Blood Pressure ?
If yes, mention your blood pressure.
Are you suffering from Diabetes ?
If yes, mention Blood Sugar
Have you suffered from any disease earlier ?
If yes, Name it
If you have recently undergone a medical check-up pertaining to blood, urine, stool, sputum, any x-ray / ultrasonography, please mention the related reports.
Any other problem that you might like to state
Is there a history of any hereditary disease in the family ?
If yes, mention it
Thank you for contacting us. We will get back to you as soon as possible
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