Name

Please fill in this form for our Senior Ayurvedic consultant to respond to your ailment

Name :

Organization :

Street Address :

City :

State :

Postal code :

Country :

Telephone :

Fax :

E-mail :

Age :

Sex :

Height :

Weight :

Structure :

Nature of work: Whether it involves constant travelling, etc:

Present complaints with full history :

Has the patient or his/her near relatives had such complaint? (Hereditary factor) if so, furnish details in brief :

Any cause known to you for the disease :

Any history of venereal disease, malaria, filaria or any other noticeable ailments:

State of digestion, motion, appetite and sleep:

Dietary habits :
Vegetarian or non vegetarian food articles being taken and their timings.

Addiction to smoking, alcohol, etc:

Marital status-married or unmarried.
Number of issues.
Menstruation, delivery, etc, problem if any:

Climate & present weather conditions of the place where he/she lives.
Any problem of pollution of air, water, etc.

Treatment done so far

Other informations, if any:

Blood pressure: