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Name: *
Age: *
Sex: Male Female
Height: * (in Centimeters)
(1 feet = 30 cms)
Weight: * (in Kilograms)
Mailing Address:
Phone/Mobile 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 day of 1st 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:
Previous Operations:
Your personal drug history. (i.e. Steroid, Insulin, Anti Hyper-tensive, Diuretic, HRT, Contraceptive Pill):
Your allergic history. (i.e. Medicine, Diet, Atmosphere):
Did any of your family member suffer from major ailment? Yes No
If yes, brief history:
Personal History
Are you dependent on: Alcohol Tobacco Smoking Drugs
Frequency and amount of addiction:
Diet: Regular Irregular
Vegetarian Non-vegetarian
Use of spicy food:
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:
Day: Night:
Micturition quantity:
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

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