Patient Enquiry - Consultation with Nirogam
Please share some more details about your medical history and lifestyle in the form below.
Our ayurvedic doctor will soon be in touch with advice on the best course of treatment for you.
If you have not yet booked a slot, please pay and book here : https://imjo.in/NpAnH
Email address *
Name *
Phone Number *
Email ID *
Place
Where are you from?
Age
Gender
Diabetes
Hypertension
Arthritis
List factors that make your condition worse
List factors that make you feel better
Sleep Pattern
Tell us how many hours sleep you get in a night
Bowel Habits
Tell us about your bowel movements
Weight
In Kilograms
Height
In Inches
Medical History
Have you had any serious illness before? If yes, please give details.
Surgical History
Have you had any minor or major surgeries? If yes, please give details.
Family Medical History
Do your parents or brother/sister have any serious illness? If yes, please give details.
Current Ailments
Give information on your current health issues.
Current Medication with Dosage
List medicines with dose and since when you're taking these medicines.
Diet
Lifestyle
Habits
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