Please Select All Answer (required)
Section A
1.Did you live in a joint family during your childhood?
Yes No
2.Do you live in a joint family now?
3.Are you in a healthy married life?
4.Are you overly protected to your family?
5.Are you the only person taking care of financial need of your family?
6.Do you have Cancer history in your family?
7.Do you have any long standing conflict in your life – personal or professional?
8.Do you feel betrayed in life?
9.Do you always help others putting your own need aside?
10.Are you going through any kind of financial crisis?
11.Do you always fear of losing in a relationship?
12.Do you feel unloved by your partner or family?
13.Do you have difficulty in expressing your love?
14.Do you feel guilty of not fulfilling needs of your loved ones?
15.Do you have difficulty in expressing your feelings when hurted by your near and dear ones?
16.Do your friends/relatives consider you as a very nice person among all the people around them?
17.Do you always put emotional need of other people before yours?
18.Do you think love is more about caring for others than loving yourself?
19.Do you love others because you think it will help you in gaining recognition from them?
Section B
1.Do you often have difficulty with breathing?
2.Do you have chronic coughing or pain in your chest area?
3.Did you notice any changes in your fingernails – black spots, or lines, whitening and thickening around the edges, and clubbing?
4.Do you feel loss of appetite and feeling full lately?
5.Did you notice rapid and unexpected weight loss recently?
6.Do you frequently having stomachache or digestive pain?
7.Are you experiencing heavy or painful periods/bleeding in between cycles?
8.Have you noticed any changes in your nipple – looking flattened, inverted or turned sideways?
9.Is your breast red, sore or swollen?
10.Have you noticed pain in your lumbar spine or lower right side lately?
11.Have you noticed any puffiness, swelling or redness in your face?
12.Is there any bleeding from the rectum or blood in stool?