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Contact
Details
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Name*
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E-mail*
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Address*
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State*
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Zip/Pin
code*
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Country*
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Telephone |
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Major
Health Details
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Your present complaint |
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Main
symptoms
and their
duration |
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History of
present
illness |
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History of previous illness
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Treatment
history
till date |
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Brief
family health history |
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Social and Occupational Details
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The exact nature
of occupation |
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Domestic and marital relationships |
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Home surroundings |
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Diet
and use of alcohol and tobacco |
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General
Details |
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Weight |
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kgs
lbs |
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Age
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Height
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feet
inches |
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Describe
bowel movements per day, or during night |
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What
is your
attitude towards self ? |
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Your
relationship to others |
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Pain-related
Details |
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your illness is associated with pain, then fill out the
following details, otherwise ignore and move on. |
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What
is the site of pain? |
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Does
it radiate
or is it localized? |
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Describe
the severity |
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Is
this the first time you are seeking Ayurvedic guidance? |
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If no, describe
the previous one
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How
did you know about us? |
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Would
you like to get our
FREE weekly Ayurvedic Newsletter ? |
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Do
you want to say something more?
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What?
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