Free Personal Health Report

Ayurvedic Consultation Form

Email address *

Contact Number

First Name *

Last Name

Address

Referral Person Name and Email

Age / Height (feet) / Weight (in Kgs)

Gender / Marital Status

Occupation

Your current health conditions

Presently using prescribed medicines if any, its details and dosages

Existing health conditions

Anemia

Constipation

Depression

Diabetes Mellifluous

Allergies

Gout

Migraine

Osteoarthritis

Rheumatoid Arthritis

Respiratory Problems

Dizziness

Thyroid Dysfunction

Fatigue

Hypertension

Peptic Ulcer

PCOD

Disability

Cold and Flu

Insomnia

High Blood Pressure

Physical characteristics

Body build

Thin

Medium

Overweight

Clear selection

Skin type

Normal

Dry

Oily

Combination

Clear selection

Sweating

Less

Normal

Excessive

Clear selection

Digestive Health

Appetite

Good Appetite

Weak Appetite

Clear selection

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)

Clear selection

Nature of thirst

Normal

Don't feel thirsty

Excessive

Clear selection

Frequency of Bowel Movement

less then 1 time per day

1-2 times per day

More than 2 times per day

Clear selection

Mind and Emotions

Sleep

Normal

Irregular

Disturbed

Insomnia

Excessive sleep

Clear selection

Dreams

Normal

Disturbing

Nightmares

Clear selection

Ease of decision making

Indecisive & Confused

Can Take Own Decisions

depends on others Advice

Clear selection

Anger

Less then one time a week

3-5 times a week

Daily

Clear selection

Worry

Less then one time a week

3-5 times a week

Daily

Clear selection

Lethargic

Less then one time a week

3-5 times a week

Daily

Clear selection

Mood swing

Less then one time a week

3-5 times a week

Daily

Clear selection

Confusion

Less then one time a week

3-5 times a week

Daily

Clear selection

Food & Exercise

Food category

vegan (fruits and vegetables )

Vegetarian (egg and milk)

Non-vegetarian

Clear selection

Exercise

None

Daily

Several Times a Week

Several Times a Month

Clear selection

Top 5 Food Items Consumed

Rice

Wheat

Vegetables

Fruits

Eggs

Meat

Fish

Cakes

Chocolates

Bakery Items

Bread

Fried Items

Packed Foods

Any immediate health goals to be achieved

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