Opening Hours : Wednesday to Monday - 10:00 A.M. to 02:00 P.M.

Free Consultation Form

 
Please Fill Up the form Below:-
Please Fill Up All The Details requested to enable us to give our best advice.
 
* Name
* Age
* Sex
* Email
* Phone No.
 
 
* Current Health Problems (Complaints)
   
* Treatments Tried & results there of
   
* Duration Of Problem
   
* Diagnosis if done by previous Doctors
   
* History Of Past illness
   
* Current Medication if any
   
* If the disease is present in your relatives (describe if any)
   
Personal  
* Marital Status
   
* Menstrual History
Age At Onset Problems if any
   
Frequency
 
Duration
Pain in abdomen
Back
Legs
Breast
Fever
Headache
Quality
   
Menopause Yes If Yes, Age Hysterectomy (Removal of Uterus) Yes If Yes, Age
  No               No  
   
* Food Habbits Timing Preference
  Vegetarian
  Both
   
Regular
Irregular
   
Spicy
Oily
Sweet
Salty
Sour
Mixed
   
* Bowel Habbits
Loose Stool
Constipated
Variable
Normal
Frequency
  Nature Of Difficulty if any
   
* Sleep
   
* General Build
   
* Temperament
Relaxed
Anxious
Prone To Anger
Easily sad
Perfectionist
* Freguency of Exercise
     
* Nature of Excercise
   
Addictions If any  
   
  Tobacoo
  Cigarettes
  Alcohol
  Drugs
  Others
   
Note : All * Fields are Mandatory