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-Select Country- Angola Argentina Australia Austria Bangladesh Belgium Bermuda Bhutan Brazil Canada Colombia Croatia Czechoslovakia Denmark Estonia Ethiopia Euthopia Finland France Germany Greece Hungary India Iran Iraq Ireland Israel Italy Jamaica Japan Kenya Lebanon Lithuania Malawi Malaysia Maldives Myanmar Nepal Netherlands New Zealand Norway Pakistan Philippines Qatar Russia Singapore South Africa Spain Sri Lanka Sudan Sweeden Switzerland Thailand U.A.E. Uganda UK USA Venezuela West Indies Other
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Please provide the following information:
Occupation E-mail
Marital Status:
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Describe your family history in brief (profession, and diseases)
Question / Health Problem Query
Give details about your addictions/cravings, if any, like tea, coffee, alcohol, sugar, smoking etc.
What is your constitution? ( To asses constitution click here)
What are the medicines you are taking at present?
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?
Why do you want to try Ayurveda?
Correspondence / Contact Address
Country / State / District
If possible, send a copy of your medical reports viz. Blood Report, X- Ray, CT Scan, MRI, etc. by email or snail mail.
