Your Name*

Age *

Sex *

Weight (Kg) *

Mobile Phone No. *

Email *

City *

Country *

Profession *

Marital Status *

1. Describe your main problems for which you want to seek our advice. *

2. For how long, are you suffering from these problems? *

3. How is your physique? *

4. How is your appetite? *

5. Do you have constipation? *
YESNO

6. Do you consume tobacco in any form? *
YESNO

7. Are you addicted to any other intoxicant (e.g., liquor/wine etc.)? *
YESNO

8. Do you take excessive quantity of tea or coffee? *
YESNO

9. Do you suffer from sleeplessness? *
YESNO

10. Do you suffer from excessive urination? *
YESNO

11. Do you feel any irritation or burning sensation while passing urine? *
YESNO

12. Do you feel palpitation of heart or pain in chest or breathlessness during physical exercise? *
YESNO

13. Are you a patient of High Blood Pressure? *
YESNO

14. Are you suffering from Diabetes? *
YESNO

15. Have you suffered from any disease earlier? *
YESNO

(a) ------If yes, name it.

16. Any other problem that you might like to state.*