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Excel Medical College for Naturopathy & Yoga
HOSPITAL ENQUIRY FORM
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Email
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Your email
Name
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Your answer
How did you hear about us?
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Google Search
FB Page
Instagram
Friends/ Relatives
Other:
Referring To
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Myself
My Parents
My Spouse
My Relatives
Others
Name of the Patient
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Your answer
Gender of the Patient
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Male
Female
Other:
Age of the Patient
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Your answer
Mobile Number
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Your answer
Address
*
Your answer
Diseases if any
*
Diabetes mellitus
Hypertension (BP)
Obesity
Sinusitis/ Allergy
Asthma/ Other Respiratory Problems
Back Pain
Knee Pain/ Neck Pain
Other Joint pain
PCOS/ Other menstrual disorders
Migraine/ Other headaches
Paralysis/ Hemiplegia
Other:
Any medications
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Your answer
Comments/ Others
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