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Provide us your basic details...
Email Id
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Name
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Gender
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Choose Gender
Male
Female
Other
Age
*
Weight(kg)
*
Height(cm)
*
Body Mass Index (BMI)
Phone No.
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Provide us your medical data...
• How long have you been suffering from constipation?
*
Choose
More than 5 years
2 to 5 years
1 to 2 years
Less than 1 year
Recently
• How often do you have bowel movements in a week?
*
Choose
Daily 1 or 2 times
3 to 4 times a week
1 to 2 times a week
Less than 1 time a week
• How satisfied are you with your bowel movements on a scale of 0 to 100, where 0 means not at all satisfied and 100 means fully satisfied?
*
Choose
0-25
26-50
51-75
76-100
• On average, how much time do you spend in the bathroom for bowel movements?
*
Choose
More than 30 minutes
20 to 30 minutes
10 to 20 minutes
5 to 10 minutes
Less than 5 minutes
• What is the type of stool that you pass?
*
  Type-1
Seperate hard lumps like nuts(Hard to pass)
  Type-2
Sausage-shaped but lumpy
  Type-3
Like a sausage but with cracks on its surface
  Type-4
Like a sausage or snake, smooth and soft
  Type-5
Soft blobs with clear-cut edges(Passed easily)
  Type-6
Fluffy pieces with ragged edges, a mushy stool
  Type-7
Watery with no solid pieces, ENTIRELY LIQUID
• Are you currently taking any medication for constipation? If yes, please list the medications.
*
Yes
No
• Do you have any of the following associated symptoms along with constipation?
*
Select
Acidity
Gas
Fullness of abdomen
Indigestion
Belching
Headache
• How would you rate your appetite and digestion in general?
*
Choose
Excellent
Good
Fair
Poor
• What is your general diet type?
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Vegetarian
Non-vegetarain
Mixed
• Is your profession one that requires you to sit for long hours?
*
Choose
Yes
No
• Do you eat salads and fruits regularly?
*
Choose
Yes, Everyday
Yes, Several times a week
Yes, occasionally
No
• Do you have a habit of sleeping late at night?
*
Choose
Yes
No
• Do you have any of the following medical conditions?
*
Select
None
Diabetes
High blood pressure
Thyroid disease
Heart problems
High cholesterol
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