Online Consultation Form
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I Am
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Basic Information
Address
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Street Address
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City
State / Province
Postal / Zip Code
Phone Number
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E-mail
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example@example.com
Occupation
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Service - Table Work
Service - Touring Job
Profession
Housewife
Student
Main Case Paper
Your Weight in KG
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Main Complaints
*
Factors - Increasing / Decreasing Symptoms
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Previous illness history
*
Any surgical history ?
*
Yes
No
If Yes...Give Details
Family History
*
Routine
Wake up
*
Before Sunrise
After Sunrise
Excercise ?
*
Daily
Sometimes
Never
Type of Job
*
Sitting Job
Hectic Job
Stressfull
In Air Conditioned
In Hot Surrounding
Shift Duty
Night Duty
Continuously in Front of PC / Laptop
Travelling Job
House Work
Your appetite?
*
Good Appetite
No feeling of Appetite
Some Times Good Some times No Feeling of Appetite
Your timing of having meal..
*
Regular
Irregular
Only After feeling of Appetite
Scheduled as per Timing
Other
Do you have breakfast ?
*
Please Select
Yes
No
Sometimes
Breakfast Timing
*
Morning
Evening
Both Times
None
Do you feel hungry at breakfast?
*
Yes
No
Do not Take Breakfast
Timing of Lunch
*
Please Select
10.00 AM - 11.00 AM
11.00 AM - 12.00 PM
12.00 PM - 02.00 PM
Before 10.00 AM
After 02.00 PM
Timing of Dinner
*
Please Select
Before Sunset
07.00 PM - 09.00 PM
09.00 PM To 10.00 PM
10.00 PM Onwards
Very Irregular
Bad Habbits
*
Cigarette
Tobacco Chewing
Gutkha
Alcohol
Use of Masheri
None
Details about Bad Habbits ( Quantity, How Many Times etc...)
Maximum Consumption of
*
Sweet Food
Sour Food
Salty Food
Bitter Food
Pungent Food
Stringent Food
Detail Routine
Daily Food Chart
*
daily
weekly
sometime
never
Hotelling
1
2
3
4
Chinese
5
6
7
8
Curd
9
10
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12
Pickle
13
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Papad
17
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20
Flakes ( Poha)
21
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24
Fried Food
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28
Sprouted Food
29
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32
Bakery Products
33
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36
Misal / Vada-paav / Samosa / Kachori etc.
37
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39
40
Fermented Food (Idli/ Dosa/Uttapa etc.)
41
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44
Gram Food ( Besan Atta Foods)
45
46
47
48
Bhel / Panipuri / Ragada pattis etc.
49
50
51
52
Stale Food ( Baansi Cheeze)
53
54
55
56
Milk Products
57
58
59
60
Sago ( Saabudaanaa)
61
62
63
64
Fasting ( Langhan / Upvaas)
65
66
67
68
Raw Food (Uncooked Food)
69
70
71
72
Nonveg
73
74
75
76
Bowel Habbits
*
Yes
No
Sometimes
Do you visit toilet daily
77
78
79
Do you have feeling of Daefication
80
81
82
Do you need Tea / Coffee / other things for Sensation
83
84
85
Nature of Stool
*
Solid
Semisolid
Watery
Sticky
Yellowish
Dark Yellowish
Brownish
Geenish
With Blood
Urine Frequency
*
2-3 times in 24 Hrs.
4-6 times in 24 Hrs.
More than 6 times in 24 Hrs.
More in Day Time & Not During Night
Sometimes during Night Also
Always during Night Also
Other
Sweating / Perspiration
*
Please Select
Continuous sweating Round the Year
Only in Summer
More Than Others
Just After Physical Work
Profuse with Smell
Stains Cloths
More on Palms
About your sleep
*
Sound sleep in Night
Breaking Sleep
Other
Do you have afternoon sleep after lunch ?
*
Please Select
Yes
No
Sometimes
Stress Level
*
Very Less
1
2
3
4
5
6
7
8
9
Too Much Stress
10
1 is Very Less, 10 is Too Much Stress
Gyanaecology - Fields for Female Patients Only
Your Menstrual Cycle
3 Days / After 28 Days
less than 3 Days / After 28 Days
4-6 Days / after 28 Days
3-5 Days / After more than 30 days
3-5 days / Before 28 Days
Other
Complaints During / Before / After Menstruation
Obstetric History
Any history of abortion / miscarriage ?
Yes
No
How many times?
Finalise your Submission
Did you take ayurvedic medicines for this / other illness ?
*
Yes
No
If yes, give details with medicines
Do you have any reports / scanned reports ?
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