Consultation

ONLINE-CONSULTATION
* An asterisk denotes required items.
Name: *
Date of Birth:
Sex: *
Height:
Weight:
Marital Status:
Occupation:
Describe your family history in brief (profession, and diseases):
Do your disease symptoms decrease or increase when you change places having different climates?
Give details aboutyour 
addictions/cravings,
if any, like tea, coffee, alcohol, sugar, smoking etc.
What are the medicines you are taking at present?
Question / Health Problem Query: *
Describe the intensity of the problem?
When does the intensity decrease by its own accord? Which factors do you feel trigger it?
What types of treatments and medicines have you taken so far? What have been the results? Have you observed any side effects?
How would you rate yourself emotionally?
What time do you usually go to sleep?
When do you wake up?
How are your dreams?
Do you want to give any other information?
Contact Address:
Country / State / District: *
Email Address: *
Phone Number:
    
 
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