HOME
|
AYURVEDA
|
ABOUT US
|
FACILITIES
|
TREATMENTS
|
PACKAGES
|
CONSULT NOW
|
OUR DOCTOR
|
GALLERY
|
CONTACT US
Consultation Form
* Fields are Compulsory
Contact Details
Name
*
:
Mr.
Mrs.
Ms.
Dr.
Drs.
Prof
Email
*
:
Address
:
State
*
:
Zip / PinCode
*
:
Country
*
:
Telephone
:
Country code
Area code
Number
Mobile
:
Major Health Details
Your Present Complaint
:
Main Symptoms and their duration
:
History of present illness
:
History of previous illness
:
Trearment history till date
:
Brief family health history
:
Social and Occupational Details
The exact nature of occupation
:
Domestic and marital relationships
:
Home Surroundings
:
Diet and use of alcohol & tobacco
:
General details
Weight
:
Kgs
lbs
Age
:
Height
:
Feet
inches
1
2
3
4
5
6
7
8
0
1
2
3
4
5
6
7
8
9
10
11
What is your attitude towards self ?
:
Your relationship to others
:
Pain-related Details
If your illness is associated with pain, then fill out the following details,
other wise ignore and move on
What is the site of pain ?
:
Does it radiate or is it localised ?
:
Describe the severity
:
Is this the first time you are seeking
Ayurvedic guidence ?
:
Yes
No
If no, describe the previous one
:
Do you want to say something more?
:
Yes
No
What ?
:
How did you know about us?
:
News paper
Magazine
Friends
Internet
Others
Copyright © 2009 Ayurlip , All rights reserved | Powered by :
Allsonet
