Online Consultancy

Name:
Age:
Sex:  Male  Female 
Occupation:
Religion:
Height:
(in Centimeters) (1 feet = 30 cms)
Weight:
(in Kilograms)
Mailing Address:
Contact Number:
Email:
Information required for consultancy
Name of disease according to modern diagnosis, If any:
Your chief compliant with their duration:
History of your disease from the 1st day symptom to other symptom in exact order of their occurrence:
Mode of onset of symptoms:
Medication/Treatment taken for the disease with their effect:
Past medical history with all the disease suffered by you:
Did any of your family member suffer from major ailment?  Yes  No 
If yes, brief history:
Personal History
Are you dependent on:
Diet:  Regular   Irregular 
 Veg   Non-Veg 
Appetite:
Frequency of tea/coffee: Per Day
Frequency of fast food: Per Week
Bowel habit:  Regular   Irregular 
 Constipation followed by 
 Constipation   Diarrhoea 
Sleep:  Deep   Sound 
 Disturbed 
Micturition frequency:(Urine)- Day:
Night:
Micturition quantity:(Urine)-  Normal   Decrease 
 Increase 
Urine Color:  Normal  Yellow  Red
Burning sensation:  Yes   No 
Body constitution:  Vata  Pita  Kapha
Mental status details:(i.e. Anxiety, Stress, Fear)-
Any other detail about you and your disease:
Your investigation reports detail:
Do you need healthy life consultancy:  Yes   No