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Please take a few minutes to fill out information on yourself. We will get in touch with you as soon as we receive your inquiry.

Here we provide a facility to you, to seek remedies for your problems. Kindly fill the following details carefully, which may help us to understand your problem and hence can suggest a good treatment to you.
Our Chief Physician Dr. Vishwavasu Gaur will suggest the treatments for your good health.

Condition at the time of admission

Name of the patient (In block letters) :

Age :

Yrs

Sex :

Male Female

Address :

Phone :

Fax :

Nationality :

E-mail :

Occupation/nature of work :

Marital status:

Single Married

Present complaints with duration of each :

Sl. No.	Name	Duration
Sl. No.	Name	Years	Months
1.
2.
3.
4.
5.
6.
7.
8.
If you need to specify anything more please add below

History of present complaints :

Detail of Investigations done so far
(Findings/impression of the experts) :

Details of the treatment already done :

Changes after taking the Ayurvedic medicines :

Current Allopathic medication if any :

Sl. No.	Name of Medicine	Dosage
1.
2.
3.
4.
5.
6.
7.
8.
If you need to specify anything more please add below

Any known allergies :

History of previous illness, if any :

Details of hereditary disease, if any :

State of	Poor	Average	Good
Digestion
Motion
Urine
Sleep
Menstruation in the case of female

Diet-Vegetarian/Non-vegetarian :

Dietary Schedule	Timings	Menu








If you need to specify anything more please add below

Addiction to smoking/alcohol/tobacco/Betel leaf :

Smoking	Alcohol	Tobacco	Betel leaf

Family history :

Details of Children/Siblings :

	Children	Siblings
Male No.
Female No.

Where patient lives :

Climate and present weather conditions of the place :

State of pollution of air, water etc. :

State of	Very Poor	Poor	Good	Very good
Air
Water

Height :

Weight :

BP :

MM of Hg

Pulse Rate :

No. /mt

Other relevant information if any :

Details of the medical reports being forwarded along with this duly filled in questionnaire :