Dheemahi Medical Questionnaire

Name*

First NameLast Name

E-mail*

Phone Number*

Country CodePhone Number

Emergency Contact*

Country CodePhone Number

Age*

MaleFemaleN/AOther

Probable Duration of stay at Dheemahi

Start Date

DayMonthYear

End Date

DayMonthYear

YesNo

Specific list of symptoms bothering you the most?

Which factors aggravate your symptoms ?

For Eg Cold or hot climate increasing joint pain, Stress increasing symptoms..

Which factors reduce your symptoms ?

For eg, rest gives lower back pain relief, exercise makes body feel lighter etc

What are your medical social expectations from a trip to Dheemahi ?

Matching your expectation with our service and Cure possibility is very important for mutual satisfaction

What is your job? How does it affect your health of mind and body?

How does family life affect your health of mind and body?

History of any Ayurvedic therapies or any form of energy healing therapies and the duration of its effect lasting in body

Current medications that you are utilizing if any

Daily Habits – Include Waking up time till sleeping time, duration of gadgets usage, Exercise routines, Meal timings..

YesNoMaybe

Ice coldNormalWarm waterOther

123More than 3

FloatSinkSome times float some times sink

SatisfactoryIncomplete

Number of urination frequency in a day ?

Day and night combined

YesNo

EasilyWith difficulty

YesNo

Sleep Duration

how many hours

YesNo

YesNoMaybe

Feel emotionally low, if so the degree of it

Height

Mention the Unit Centimetres or Inches

Weight

Mention the Unit Kilo Gram or Pounds

YesNoMaybe

Menstrual history and present pattern, regularity, flow quantity , specific features Obstetrics history if relevant

Medical Records

Upload Files

Upload relevant medical records

Room Type - All inclusive cost

Daily upto 90 / 180 minutes treatment sessions are available

Number of guests*

Enter the number

Pick me up on arrivalI'll make my own way there

Special Requests

A copy of your responses will be emailed to the address you provided.