Free Consultancy

Your Personal Details:

Country:
Height:
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Inches: 012345678910111213141516

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?LowNormalHigh

*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? YesNo

*How often do you have constipation and what do you think are the causes?

*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? YesNo

Sleep:

Do you have sound sleep? YesNo

Mental Condition:

How would you rate yourself emotionally?
AnxiousNervousWorrisomeDepressedTenseRelaxedIrritableImpatientPatientCalmLethargicEnergeticCompetitiveDrivenRestlessIndecisive

*Describe your economical condition

Your Treatment History:

*What types of treatments and medicines have you taken so far?
*What have been the results?

*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? YesNo
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-menopausalPost-menopausalN.A
What are your post-menopausal complaints?
Are you currently on hormone replacement therapy (HRT)? N.AYesNo
Would you like to have a safe Ayurvedic alternative to HRT? YesNoN.A
How are your periods? RegularIrregularN.A
Do you want to give any other information?

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