| Consultation Form |
| Your Personal
Details |
*Your
Name : |
|
*Your
E-Mail : |
|
*Phone
:(Include Country/Area Code) |
|
Fax
:(Include
Country/ Area Code) |
|
Street
Address : |
|
*City/State
: |
|
*Zip/Postal
Code : |
|
*Country
: |
|
*Height |
Feet
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? |
|
*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? |
|
| Mental
Condition: |
How
would you rate yourself emotionally? |
(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? |
|
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? |
|
What
are your post-menopausal complaints? |
|
Are
you currently on hormone replacement therapy (HRT)? |
|
Would
you like to have a safe Ayurvedic alternative to HRT? |
|
How
are your periods? |
|
Do
you want to give any other information? |
|
| * Essential Fields |
|
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