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Please take a few minutes to fill out information on yourself. We will get in touch with you as soon as we receive your inquiry.

Here we provide a facility to you, to seek remedies for your problems. Kindly fill the following details carefully, which may help us to understand your problem and hence can suggest a good treatment to you.
Our
Chief Physician Dr. Vishwavasu Gaur will suggest the treatments for your good health.


Condition at the time of admission

Name of the patient (In block letters) :

Age :

 Yrs

Sex :

 Male    Female

Address :

Phone :

Fax :

Nationality :

E-mail :

Occupation/nature of work :

Marital status:

 Single    Married

Present complaints with duration of each :

Sl. No.

Name

Duration

Years

Months

1.

2.

3.

4.

5.

6.

7.

8.

If you need to specify anything more please add below

History of present complaints :

Detail of Investigations done so far
(Findings/impression of the experts) :

Details of the treatment already done :

Changes after taking the Ayurvedic medicines :

Current Allopathic medication if any :

Sl. No.

Name of Medicine

Dosage

1.

2.

3.

4.

5.

6.

7.

8.

If you need to specify anything more please add below

Any known allergies :

History of previous illness, if any :

Details of hereditary disease, if any :

State of

Poor

Average

Good

Digestion

Motion

Urine

Sleep

Menstruation in the case of female

Diet-Vegetarian/Non-vegetarian :

Dietary Schedule

Timings

Menu

If you need to specify anything more please add below

Addiction to smoking/alcohol/tobacco/Betel leaf :

Smoking

Alcohol

Tobacco

Betel leaf

Family history :

Details of Children/Siblings :

Children

Siblings

Male No.

Female No.

Where patient lives :

Climate and present weather conditions of the place :

State of pollution of air, water etc. :

State of

Very Poor

Poor

Good

Very good

Air

Water

Height :

Weight :

BP :

 MM of Hg

Pulse Rate :

 No. /mt

Other relevant information if any :

Details of the medical reports being forwarded along with this duly filled in questionnaire :