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Consultation
Form |
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Your
Personal
Details |
( *
Fields are mandatory) |
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Name |
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Address |
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Phone |
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Age |
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Occupation |
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Email Id* |
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Height |
Feet
Inches
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Weight |
pounds |
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Your Health
Details |
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Name your
disease,
chief signs, symptoms (as
diagnosed by
conventional/modern
medicine) |
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General Diet |
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Diet details |
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Complete
History of
Disease |
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Do your
symptoms/complaints
decrease or
increase
when you
change
climatic
zones? |
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What kind of
food,
lifestyle or
environmental
changes
relieve the
nature of
your
complaints? |
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What kind of
food,
lifestyle or
environmental
changes
trigger the
symptoms of
your
disease? |
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Digestive
System |
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How is your
appetite and
digestion? |
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Give
complete
details of
your bowel
movements,
such as time
of
evacuations,
frequency,
color,
consistency,
regularity,
irregularity
and smell. |
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Do you see
any Mucus in
your stool? |
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How often do
you have
constipation and
what do you
think are
the causes? |
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Do you pass
wind? |
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Do you have acid reflux/heartburn? |
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Do you
experience
heaviness,
discomfort
or
pain in
the stomach
after
eating? |
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Urinary
System |
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What is the
frequency,
quantity and
color of
your urine? |
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Do you feel
any burning
sensation
while
urinating? |
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Sleep |
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Do you sleep
soundly? |
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Mental
Condition: |
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How would
you rate
yourself
emotionally? |
(press
'ctrl' and
click for
multiple
selection) |
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How do you
perceive
your own
financial
status? What
are your
comfort
levels with
your current
situation? |
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Your
Treatment
History |
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What types
of
treatments
and
medicines
have you
taken so
far? |
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What have
been the
results? |
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Have you
observed any
side-effects? |
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How much do
you know
about
CureVeda? |
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Reproductive
System |
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Mention, if
you have any
sexual
problems |
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Are there
any other
details you
would like
to share? |
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