feedback form
*Fields are Compulsory
Contact Details
 
Name*    
:
      
Email*     
:
    
Address*    
:
    
State*    
:
    
Zip/PinCode*    
:
    
Country*  
:
    
Telephone  
:
    
  : Country Code
i
   
:
 Area Code  
    : Number  
 
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 ofalcohol andtobacco   :  
General details
Weight   :              
Age   :  
Height   :   feet       inches
Describe bowel movements per day,or during night   :  
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,otherwise 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 ?   :  
If no,describe the previous one   :  
How did you know about us?   :  
Would you like to get our FREE weekly Ayurvedic Newsletter   :  
Do you want to say something more?   :     what?