Consultation
Form
Your
Personal
Details
( *
Fields are mandatory)
Name
Address
Phone
Age
Occupation
Email Id*
Height
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Feet
0
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Inches
Weight
pounds
Your Health
Details
Name your
disease,
chief signs, symptoms (as
diagnosed by
conventional/modern
medicine)
General Diet
Diet details
Complete
History of
Disease
Do your
symptoms/complaints
decrease or
increase
when you
change
climatic
zones?
What kind of
food,
lifestyle or
environmental
changes
relieve the
nature of
your
complaints?
What kind of
food,
lifestyle or
environmental
changes
trigger the
symptoms of
your
disease?
Digestive
System
How is your
appetite and
digestion?
Normal
Low
High
Give
complete
details of
your bowel
movements,
such as time
of
evacuations,
frequency,
color,
consistency,
regularity,
irregularity
and smell.
Do you see
any Mucus in
your stool?
Yes
No
How often do
you have
constipation and
what do you
think are
the causes?
Do you pass
wind?
Do you have acid reflux/heartburn?
Do you
experience
heaviness,
discomfort
or
Urinary
System
What is the
frequency,
quantity and
color of
your urine?
Do you feel
any burning
sensation
while
urinating?
Yes
No
Sleep
Do you sleep
soundly?
Yes
No
Mental
Condition:
How would
you rate
yourself
emotionally?
Anxious
Nervous
Worrisome
Depressed
Tense
Relaxed
Irritable
Impatient
Patient
Calm
Lethargic
Energetic
Competitive
Driven
Restless
Indecisive
(press
'ctrl' and
click for
How do you
perceive
your own
financial
status? What
are your
comfort
levels with
your current
situation?
Your
Treatment
History
What types
of
treatments
and
medicines
have you
taken so
far?
What have
been the
results?
Have you
observed any
side-effects?
How much do
you know
about
CureVeda?
Reproductive
System
Mention, if
you have any
sexual
problems
Are there
any other
details you
would like
to share?
