Consultation Form
Your Personal
Details
*
Your Name :
*
YourE-Mail :
*
Phone:
Fax:
(Include Country/ Area Code)
Street Address :
*
City/State:
*
Zip/Postal Code :
*
Country :
*
Height
—Please choose an option— 0 1 2 3 4 5 6 7 8 Feet
—Please choose an option— 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Inches
*
Weight
Pounds
Occupation
Climate you live in
Your Health Details
*
What is the name of your disease as diagnosed by conventional medicine?
*
What are the chief signs, symptoms or complaints that forced you to turn to our Ayurveda Doctors?
General Diet
*
Diet details
Complete History of Disease
*
Does your disease symptoms increase or decrease when you change climatic zones?
*
What kind of food, lifestyle or environmental changes relieves the symptoms of your disease and which ones trigger them?
Digestive System
How is your appetite and digestion?
Low Normal High
*
Write the complete details of your bowel movements, such as, time of evacuations, frequency, color, consistency, regularity,irregularity and smell.
Do you see any mucus in your stool?
Yes No
*
How often do you have constipation and what do you think are the causes?
*
Do you pass flatulence?
*
Do you have hyperacidity?
*
Do you feel heaviness, discomfort and pain in your stomach after eating?
Urinary System
*
What is the frequency, quantity and color of your urine?
Do you feel any burning sensation while urinating?
Yes No
Sleep
Do you have sound sleep?
Yes No
Mental Condition:
How would you rate yourself emotionally?
Anxious Nervous Worrisome Depressed Tense Relaxed Irritable Impatient Patient Calm Lethargic Energetic Competitive Driven Restless Indecisive
(press 'ctrl' and click for multiple selection)
*
Describe your economical condition
Your Treatment History
*
What types of treatments and medicines have you taken so far?
*
What have been the results?
*
Have you observed any side effects?
*
How much do you know about Ayurveda?
Reproductive System
Mention,if you have any sexual problem
Are there any other details you would like to mention?
Your Gynecological History (For female patients only)
Are you married?
Yes No
At what age were you married?
Since how many years are you married?
How many children do you have? How old are they?
Are you in the pre or post-menopausal phase of life?
Pre-menopausal Post-menopausal N.A
What are your post-menopausal complaints?
Are you currently on hormone replacement therapy (HRT)?
N.A Yes No
Would you like to have a safe Ayurvedic alternative to HRT?
Yes No N.A
How are your periods?
Regular Irregular N.A
Do you want to give any other information?
*
Essential Fields
