Childlessness Female Treatment Form
Fill all the Fields, If you want Complete Treatment

     
  *Name
  *E-mail
  *Address
  *City
  *State
  *Zip Code
  *Country
  *Mobile Number
  *Phone Number
  *Fax Number
  Age
  Weight
  Height
  Occupation
 
Mention the reason your pregnancy failures
When did you get your pregnancy last?
     
  Do you have child bearing problem
If so, since how long		 Yes No
  How about your mensuration period?

If early or delayed, mention the days

Normal Early Delayed

  How many days your mensuration lasts?
  Do you feel extreme pain at the time of mensuration? Yes No
  Do you get normal sleep? Yes No
  How many times you pass urine at night?
  Do you feel to much hungry? Yes No
  Do you have constipation? Yes No
  Do you feel uncomfortable or pain while passing urine? Yes No
  Do you feel extra pain at the time of (intercourse) union with your male companion? Yes No
  Is your husband suffering from any sexual disorder?
If so specify		 Yes No
  Have your husband taken any treatment or test for infertility or any other sex disorder?
If so, specify		 Yes No
  How about your memory Sharp Weak
  Do you feel irritation in both legs and hands? Yes No
  Do you smoke or take alcoholic drinks? Yes No
  What kind of medicines you have taken earlier to cure your problem?
 
Specify whether you have done the following tests:
     

1. Fallopian Tubes
Closed or Damaged EitherBoth Or One

2. Uterus
Whether there is tumours or infection?
Yes       No

3-. Ovaries
Whether the mouth closed
Yes No

     
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