UTI Questionnaire - HomeopathicVibes

Call Us: (408)-737-7100
Our Address: 940 E El Camino Real, Sunnyvale, CA - 94087 | 39039 Paseo Padere Parkway,Suite #209,Fremont, CA 94538

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UTI Questionnaire

Why Me?

I'm providing homeopathic services for over 20 years in entire California. My clinic is located in Sunnyvale, Fremont, and San Jose. I have treated more than 1000 patients suffering from various conditions. I also provide online consultation if you're not able to visit any of my clinics. I have more than 100 five stars reviews on Google, Yelp, and other reviews websites. If you would like to know more about me, then feel free to reach me out by phone.

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Conditions We Treat

Skin Conditions
Neurological Conditions
Stomach Conditions
Pulmonary Conditions
Alcoholism
Autoimmune Disease
Women’s Conditions

UTI Questionnaire

940 E. El Camino Real
Sunnyvale, CA 94087
harminder@homeopathicvibes.com
www.homeopathicvibes.com
Office Phone (408)737-7100
Office Fax (408)737-7102

Name *

First

Last

Email *

Marital status

Married
Single
Widow
Divorced
Separated

Do you feel any kind of pain?

Before Urination
After Urination

Do you feel any kind of burning?

Before Urination
After Urination

Do you notice any blood in urine?

Yes
No

Do you notice any pus in urine?

Yes
No

Do you notice any abnormal discharge urine?

Yes
No

Do you notice any kind of swelling around vulva?

Yes
No

Do you experience any kind of Itching around vulva?

Yes
No

All the complaints increase after intercourse?

Yes
No

Mostly my UTI happen?

Before Urination
After Urination
Do not apply

How often you have UTI s in past 6 months?

Only once
2-3 times
more than 3 times

What was your usual duration of infection without any treatment?

1-3 days
3-7 days
More than 7 days.

13. What was your usual duration of infection with any treatment?

1-3 days
3-7 days
More than 7 days.

Are you using any contraceptive devices?

Yes
No

If yes, since how long?

Are you using any lubricating jelly?

Yes
No

If yes, since how long?

Does your husband use condoms?

Yes
No

If yes, which one?

Latex
Rubber

Are you a

Vegetarian
Non Vegetarian

Which types of food do you like?

Spicy
Mild

Do you have any Gastric Problem?

Yes
No

Are you suffering from blood pressure. If so, whether it is?

High
Low

Do you sleep well?

No
Yes

How many times you wake up to urinate during night?

I don’t wake up.
1-3 times.
4-6 times.
More than 6 times

Do you exercise daily

No
Yes

Your partner has any sexual problem?

No
Yes

Have you ever been treated in past?

No
Yes

If so details

Have you ever had kidney infection?

No
Yes

Have you ever had kidney pain?

No
Yes

What are your expectations from our treatment?

I don’t expect good results
I expect good results.
I would be happy if I improve.
I am confident

Are you willing to make changes to your life style or diet modifications?

I can not change my lifestyle
I have tried nothing works for me
I am willing to change my lifestyle if needed
I am willing to do what ever is needed to get best results

Name

About Me

I have passion for homeopathy. I am blessed to be born in family of Homeopaths. My grand father Dr. Hazara Singh Gill was great homeopath of his times. He did his M.B.H (Bachelor of Medicine in Homeopathy) from Punjab Homeopathic Medical College Lahore in 1925.

Sunnyvale Location

Phone: 408-737-7100
Fax: 408-737-7102
Address: 940 E El Camino Real, Sunnyvale, CA 94087, United States
harminder@homeopathicvibes.com

Fremont Location

Phone: 408-737-7100
Fax: 408-737-7102
Address: 39039 Paseo Padere Parkway,Suite #209,Fremont, CA 94538, USA.
harminder@homeopathicvibes.com

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Weekdays: 10:00 am - 6.00 pm
Weekend: By Appointment only

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