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Provide us your basic details...

Email Id*

Name*

Gender*

Age*

Weight(kg)*

Height(cm)*

Body Mass Index (BMI)

Phone No.*

Provide us your medical data...

• How long have you been suffering from constipation?*

• How often do you have bowel movements in 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?*

• On average, how much time do you spend in the bathroom for bowel movements?*

• 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. *

• 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?*

• What is your general diet type?*

• Is your profession one that requires you to sit for long hours?*

• Do you eat salads and fruits regularly?*

• Do you have a habit of sleeping late at night?*

• 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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