+91-9897551272 , +91-9897379307

PATIENT INFORMATION FORM

    Name* :


    Age* :


    Gender* :


    Weight* :


    Height* :


    Location* :


    Occupation* :


    Contact number* :


    Email* :


    How do you feel leakage of Urine ?


    a) Is there any Urgency of Urine?*


    b) Is there more frequency of Urine?*


    c) Is there any dribbling after Urination?*


    d) Do you feel any bulge on your anterior wall of Vagina?*


    e) Do you feel laxity of Pelvic floor muscles?*


    f) Is there any History of Urinary Tract Infection (UTI)*


    Any Medical History of :


    Surgeries* :


    Injuries* :


    Child birth* :


    Illness* :


    Other diseases like Diabetes, Kidney Problem and any other Neurological problems?*


    Social History* :


    Smoking* :


    Alcohol* :


    Any other Addiction?*


    How is Your Bowel Movement?*


    Duration of the Problem?*


    Past and Current problems with your Urinary System?*


    Any Type of Treatment or Medicine which you are taking at present?*


    Any Thing which you want to share?*

    Please prove you are human by selecting the car.

    Enquire Now

    About Us


    Dr. H.B Shandilya, Ayurvedacharya (B.A.M.M.S) Bachelor of Ayurveda with Mordern Medicine & Surgery Institutionally qualified from a renowned Govt. Ayurvedic College Lucknow under Lucknow University.

    Having served for over 40 Years, I have attained prowess on treating Pelvic Organ Prolapse (POP) and Urine Incontinence in WOMEN with Unique Miraculous Poly Herbal Formula which is clinically time tested . We are from a traditional family of Ayurveda.

    Contact Us


    Adresss
    Kalptaru Herbal Therapy Centre ,
    Saharanpur Road,
    Herbertpur,
    District Dehradun (Uttarakhand)

    Mobile
    +91 989 737 9307
    +91 989 755 1272

    E-Mail
    info@leakageurine.com
    therapycentrekalptaruherbal@gmail.com