header image Professor Hakim Dilshad Hussain Tabssum (Gold Medalist) Ex-member: American Infertility Association (USA)
 
 

Female Infertility Form

female-form
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  Yes No
If so, since how long Years
Your menstruation periods are  Normal Early Delayed
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  Yes No
Do you get normal sleep  Yes No
How many time you pass urine at night times
Do you feel to much hungry  Yes No
Do you have constipation  Yes No
IDo you feel uncomfortable or pain while passing urine  Yes No
Do you feel extra pain at the time of intercourse  Yes No
After intercourse semen flows inside vagina  Yes No
Leucorrhoea Problem  Yes No
Is your hasband suffering from any sexual disorder  Yes No
If so, specify
How about your memory  sharp Weak
IDo you feel irritatin in both legs and hands  Yes No
Do you smoke or take alcoholic drinks  Yes No
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 Damaged Both One 

2. Ulterus
Whether there is tumors or infection?
Yes No 

3. Ovaries
Whether the mouth closed
Yes No 

Main Problem
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