Since when have you been diagnosed with cholesterol ?WeeksMonthsYears
Is there a family history of high cholesterol?YesNoNot Sure
Do you have any cardiac problems?YesNoIf yes, then please mention the details in the 'more information' column at the end of the questionnaire
Do you suffer with high blood pressure?YesNoNot Sure
Do you have any pain or discomfort in your chest ?YesNoOccasionally
Do you smoke?YesNoOccasionally
Do you eat a lot of non vegetarian food?YesNoOccasionally
Do you exercise regularly?YesNoOccasionally
Have you got your lipid profile done?(Please mention the details of the reports in the 'more symptoms' column)YesNo
Are you already a patient with Dr.Manoj's Homeopathy? If yes please state your Registration Number in the text box.YesNo
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Gender:MaleFemale
Age:-Select-1 Month2 Months3 Months4 Months5 Months6 Months7 Months8 Months9 Months10 Months11 Months12 Months234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859606162636465666768697071727374757677787980818283848586878889909192939495969798
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