FEMALE TREATMENT FORM
Fill in all the fields, if you want complete treatment

* Name
* E-mail
*Address
*City
*State
*Zip Code
* Country

Age
Weight
Height
Occupation
Are you married If so, How long	Yes No
Mention the reason your pregnancy failures
For how long your pregnancy last
Do you have child bearing problem	Yes No No If so, how long?
Mention if you not get pregnancy at all
How about your mensuration period	Normal Early Delayed
If early or delayed, mention the days
How many days mensuration last
Do you feel extreme pain at the time of mensuration	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	Yes No If so specify?
Do you feel irritation in both legs and hands	Yes No
Do you smoke	Yes No
Do you take alcoholic drinks	Yes No
What kind of medicines you have taken earlier.
Specify whether you have done the following tests:
1. Fallopian Tubes	Closed or Damaged Either Both Or One
2. Uterus Whether there is tumours or infection	Yes No
3. Ovaries Whether the mouth closed	Yes No
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