Free Personal Health Report
Ayurvedic Consultation Form
* Required
Email address
*
Your email
Contact Number
Your answer
First Name
*
Your answer
Last Name
Your answer
Address
Your answer
Referral Person Name and Email
Your answer
Age / Height (feet) / Weight (in Kgs)
Your answer
Gender / Marital Status
Your answer
Occupation
Your answer
Your current health conditions
Presently using prescribed medicines if any, its details and dosages
Your answer
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
Your answer
Submit
Page 1 of 1
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms