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feedback form
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*Fields
are Compulsory
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Contact Details
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| Name*
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Mr.
Mrs.
Ms.
Dr.
Drs.
Prof
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| Email*
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| Address*
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| State*
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| Zip/PinCode*
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| Country* |
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Afghanistan
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Country Code |
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Area Code
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Number |
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Major Health Details
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| Your Present Complaint
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| Main Symptoms and their
duration
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| History of present illness
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| History of previous illness |
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| Trearment
history till date
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| Brief family
health history
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Social and Occupational Details
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| The exact nature
of occupation
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| Domestic and
marital relationships
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| Home
Surroundings |
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| Diet and use
ofalcohol andtobacco
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General details
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| Weight |
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Kgs
lbs
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| Age |
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| Height |
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1
2
3
4
5
6
7
8
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feet |
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1
2
3
4
5
6
7
8
9
10
11
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inches |
| Describe bowel
movements per day,or during night
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| What is your
attitude towards self ?
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| Your
relationship to others
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Pain-related Details
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If your illness is associated with pain,then fill out the
following details,otherwise ignore and move on
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| What is
the site of pain ?
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| Does it
radiate or is it localised ?
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| Describe the
severity
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| Is this the
first time you are seeking Ayurvedic guidence ?
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Yes
No
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| If no,describe
the previous one |
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| How did you know
about us? |
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| Would you like
to get our FREE weekly Ayurvedic Newsletter
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| Do you want to
say something more? |
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Yes
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what? |
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