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Female Infertility Form

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The following Performa is formulated to help you to specify your problems correctly & this enable to analyze your ailments accurately. Chief Executive of Tibb-e-Islami Dawakhana (Regd.) Professor Hakim Dilshad Hussain Tabassum personally goes through every e-mail & a panel of expert Hakims review every individual case. Our unani medicines has a legacy of more than 1000 years of tradition & knowledge and our medicines are prepared strictly in accordance with the age old medical scripts, texts & manuals of unani practice with the help of modern scientific tools. Now world renowned western doctors has conceded that where modern medicine failed to cure, there “unani herbalism” steps in to cure the incurable. Today unani medicine is recognized worldwide by World Health Organization (WHO) as one of the alternative system of medicines & forms an integral part of national health care delivery system. For those who are unable to find a solution, we show them right direction through our valuable consultation. We remind you that the root cause of all sexual disorders lies in the ignorance, bad habits, wrong life styles & unnatural sex acts of younger days. These destroy one’s own body & health. Our treatment will certainly help you to live a long life free from these diseases.

Your Name
Occupation
E-mail
Address
City
State
Zip Code
Country
Age years
Weight Kg
Height (i.e., 5" 6" or 5f 6i)
Reason for you pregnancy failures when did you last get pregnant
Please type date here
Do you have child bearing problem YesNo
If so, since how long Years
Your menstruation periods are NormalEarlyDelayed
If early or delayed, mention the days days
How many days your menstruation lasts day
Do you feel extreme pain at the time of menstruation YesNo
Do you get normal sleep YesNo
How many time you pass urine at night times
Do you feel to much hungry YesNo
Do you have constipation YesNo
IDo you feel uncomfortable or pain while passing urine YesNo
Do you feel extra pain at the time of intercourse YesNo
After intercourse semen flows inside vagina YesNo
Leucorrhoea Problem YesNo
Is your hasband suffering from any sexual disorder YesNo
If so, specify
How about your memory sharpWeak
IDo you feel irritatin in both legs and hands YesNo
Do you smoke or take alcoholic drinks YesNo
What kind of medicine you have taken earlier to cure your problem

Specify whether you have done the following tests:


1. Fallopian Tubes
Closed or DamagedBothOne

2. Ulterus
Whether there is tumors or infection?
YesNo

3. Ovaries
Whether the mouth closed
YesNo

Main Problem
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