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Free Ayur Wellness Consultation
Free Ayur Wellness Consultation
Ayur Wellness Consultation
Ayurvedic Consultation Form
Contact Details
Name
*
First
Last
Email
*
Contact Number
*
Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia (Republic of)
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States of America
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Viet Nam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Referral Person Name
Referral Person Email / Phone Number
General Information
Age
*
Occupation
Height
*
Weight
*
weight measured in
*
Kilogram
Pounds
Gender
*
Male
Female
Other
Marital Status
Unmarried
Married
Divorced
In-relationship
Alchohol Intake
never
seldom
weekly once
several times a month
Tobacco Intake
never
seldom
weekly once
several times a month
Drug & Substance use
never
seldom
weekly once
several times a month
Your current health conditions
what is the reason for consultation
*
Presently using prescribed medicines if any, its details and dosage
Doctor's name/hospital/city from where using the above medicines
Test and investigation reports (write conclusions of reports)
Upload your reports
Other health conditions (secondary problems)
aneamia
constipation
depression
diabetes mellitus
allergies
gout
migraine
hypertension
osteoarthritis
peptic ulcer
rheumatoid arthritis
respiratory problems
dizzness
fatigue
wheezing
thyroid dysfunction
PCOD
Physical characteristics
Body build
thin
medium
underweight
overweight
obese
emaciated
Skin type
dry&rough
soft&slight oil
softer&oily
Sweating
less
normal
excessive
Digestive Health
Appetite
good appetite
complete loss of appetite
weak appetite(don't feel much appetite can skip meal)
Digestion
very weak( can't digest food)
weak(can digest food but sometimes feel discomfort)
good(i can digest food)
great( i can digest every thing comes to my plate)
Nature of thirst
normal
don't feel thirst
excessive
Frequency of bowel movement
1-2 times per day
2-3 times per day
more than 3 times per day
once in two days
twice a week
Mind and Emotions
Sleep
normal
irregular
disturbed
insomnia
excessive sleep
Dreams
normal
disturbing
nightmares
Ease of decision making
indecisive and confused
can take own decisions and make goals
follow advice
take advice from many people and take a decision
Anger
none
daily
several times a week
several times a month
Worry
none
daily
several times a week
several times a month
Lethargic
none
daily
several times a week
several times a month
Mood swing
none
daily
several times a week
several times a month
Confusion
none
daily
several times a week
several times a month
Habits and Life Style
Food category
vegetarian
non-vegetarian
ovo vegetarian
Food items consumed
rice
wheat
vegetables
fruits
eggs
meat
fish
cakes
chocolates
bakery items
fried items
bread
packed foods
Excercise
none
occasional
daily
several times a day
several times a month
Excercise duration
30 min per day
less than 30 min per day
more than 30 per day
what do you expect from this online ayurvedic consultation?
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