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W.I.S.E Preliminary Patient Form
1. You are eligible to fill this form only if you have a single disease/ आप केवल एक स्वास्थय समस्या/ बीमारी के लिए ही फॉर्म भर सकते है
2. History of the disease should not be more than 5 years/आपकी स्वास्थय समस्या पांच साल से पुरानी नहीं होनी चाहिए
3. This service is chargeable. To receive a diet plan you will need to pay INR 500/- into W.I.S.E Practitioner Paytm number./ कंसल्टेशन शुल्क 500 रुपए लागू (Paytm द्वारा W.I.S.E. प्रैक्टिशनर के अकाउंट में ट्रांसफर )
4. Valid for 3 Weeks/ 3 हफ्ते के लिए वैध
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* Indicates required question
Email
*
Your email
Are you vaccinated for Covid-19 ?
*
It has been brought to the attention of patient that DIP Diet is not tested on large scale on vaccinated people, so result of DIP Diet on vaccinated people is unknown
Yes
No
Patient Name/रोगी का नाम
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Your answer
Email Id /ईमेल (आपको डाइट प्लान ईमेल द्वारा भेजी जाएगी )
*
Your answer
Phone Number/मोबाइल नंबर
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Your answer
Whatsapp Number/ Whatsapp नंबर
*
Your answer
City
*
Your answer
State
*
Your answer
Age/आयु (DD/MM/YYYY)
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MM
/
DD
/
YYYY
Name of the Medical Condition/conditions/अपनी हेल्थ कंडीशन / समस्या /रोग
*
Choose
ACIDITY
ALZHEIMER
ANEMIA
ANGINA
ASTHMA
BACK PAIN
BRONCHITIS
CATARACT
CONSTIPATION
DEMENTIA
DEPRESSION
DIABETES TYPE 2
ECZEMA
ENLARGED PROSTATE
FATTY LIVER
GAS
GLAUCOMA
HEPATITIS
HIGH BLOOD PRESSURE
HIGH CHOLESTEROL
IMPOTENCY
INFERTILITY
INSOMNIA
JOINT PAIN
KIDNEY STONE
LIVER CIRRHOSIS
LOW BLOOD PRESSURE
LOW BODY WEIGHT
MIGRAINE
OBESITY
PARKINSON
PERIODS WITH EXCESSIVE BLEEDING / PCOD
PILES / IBS
PRE-MENSTRUAL SYNDROME / PAINFUL PERIODS /
PSORIASIS
SCIATICA
SINUSITIS
SPONDYLOSIS
THYROID
ULCER
URINARY TRACT INFECTION
VARICOSE VEINS
WEAK IMMUNITY
Others
If the name of your health problem is not mentioned in the above list. Please Click the below given link / कृपया अपनी हेल्थ कंडीशन / समस्या /रोग का नाम लिखिए यदि उपरोक्त सूची में आपकी स्वास्थ्य समस्या का नाम नहीं है।
Your answer
Since when do you have this medical condition/आपको यह स्वास्थ्य समस्या कब से है
*
Your answer
Present symptoms & discomforts:/फॉर्म भरते समय क्या आपको कोई परेशानी /तकलीफ है ? अगर है तो लिखिए
*
Your answer
Name of the medicines taken presently/क्या आप कोई दवा ले रहे हैं। यदि हाँ, तो कृपया अपने द्वारा ली जा रही दवाओं का नाम लिखें। अगर नहीं तो "NA" लिखे
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Your answer
How did you know about WISE/ आपको WISE के बारे में कैसे पता चला?
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YouTube Video
Facebook
NICE EXPERT
Through Friends/ relatives/ someone
Other(Write name of the person below)
__________________________________________________
Required
Please mention the name of the NICE Expert who recommended you to fill the WISE Form/कृपया NICE एक्सपर्ट के नाम का उल्लेख करें, जिसने आपको WISE फॉर्म भरने की सिफारिश की थी
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Your answer
If You chose 'Others' Please mentioned where you learned about WISE / यदि आपने 'दूसरों' को चुना है तो कृपया उल्लेख करें कि आपने WISE / के बारे में कैसे पता है?
*
Your answer
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