Health Consultation Form

Fill out the contact information below so we can contact you and serve you as best as we can!

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* Required

First Name
*

Last Name
*

Phone Number
*

Email Address
*

Personal Details

Sex
*

• 
  Male
• 
  Female

Age
*

Weight
*

Bowel
*

• 
  Regular
• 
  Irregular
• 
  Hard Stool
• 
  Loose motion

Appetite
*

• 
  Good
• 
  Less
• 
  Irregular
• 
  More

Urine
*

• 
  Nothing Special
• 
  More frequent
• 
  incontinance

Sleep
*

• 
  Sound
• 
  Delayed
• 
  Not continuous
• 
  More

Digestion
*

• 
  Bloated
• 
  Indigestion
• 
  Burning
• 
  Painful

Exercise
*

• 
  Good
• 
  Medium
• 
  Less

Mind
*

• 
  Stressed
• 
  Peaceful
• 
  Depressed

Do you drink alcohol?
*

Yes No

Diet
*

• 
  Vegitarian
• 
  Mixed

Disease Details

Details of past medication or Hospitalization if any

Medical Condition(s) - (Check all that apply)
*

• 
  Acid Reflux
• 
  Acne
• 
  Allergies
• 
  Attention Deficit Disorder
• 
  Alzheimer's Disease
• 
  Anorexia
• 
  Arthritis - Osteo
• 
  Arthritis - Rheumatoid
• 
  Asthma
• 
  Back Pain
• 
  Bipolar Disorder
• 
  Brain Injury
• 
  Bronchitis
• 
  Bulimia
• 
  Bursitis
• 
  Cancer – Bladder
• 
  Cancer – Brain
• 
  Cancer – Cervical/Endometrial/Ovarian
• 
  Cancer – Colon/Rectal
• 
  Cancer – Kidney
• 
  Cancer – Lung
• 
  Cancer – Leukemia
• 
  Cancer – Non-Hodgkin’s Lymphoma
• 
  Cancer – Pancreatic
• 
  Cancer – Prostate
• 
  Cancer – Skin
• 
  Cancer – Other
• 
  Celiac Disease
• 
  Cholesterol (High)
• 
  COPD
• 
  Congestive Heart Failure
• 
  Crohn's Disease
• 
  Depression
• 
  Diabetes – Type 1
• 
  Diabetes – Type 2
• 
  Diarrhea
• 
  Disabilities (Mental or Physical)
• 
  Diverticulitis
• 
  Ear Infections
• 
  Ear Problems (Other)
• 
  Eczema
• 
  Endometriosis
• 
  Enlarged Prostate
• 
  Epilepsy
• 
  Erectile Dysfunction
• 
  Eye Problems
• 
  Fibromyalgia
• 
  Gallbladder Disease
• 
  Gallstones
• 
  Generalized Anxiety Disorder
• 
  Genital Herpes
• 
  Glomerulonephritis (Nephritis)
• 
  Gout
• 
  Headache
• 
  Hearing Loss
• 
  Heart Disease
• 
  Heartburn
• 
  Hemorrhoids
• 
  Hepatitis
• 
  Herniated Discs
• 
  Hiatal Hernia
• 
  HIV/AIDS
• 
  HivesHigh Blood Sugar
• 
  High Blood Pressure
• 
  High Potassium
• 
  Hyperthyroidism
• 
  Hypothyroidism
• 
  Infertility
• 
  Insulin Dependent Diabetes Mellitus (IDDM)
• 
  Iron Deficiency Anemia
• 
  Irritable Bowel Syndrome (IBS)
• 
  Itching
• 
  Juvenile Rheumatoid Arthritis
• 
  Kidney Disease
• 
  Kidney Stones
• 
  Lupus
• 
  Memory Loss
• 
  Menopause
• 
  Mesothelioma
• 
  Migraine
• 
  Multiple Sclerosis (MS)
• 
  Muscle Cramps
• 
  Muscular Dystrophy
• 
  Muscle Fatigue
• 
  Muscle Pain
• 
  Obesity
• 
  Osteomyelitis
• 
  Osteoporosis
• 
  Ovarian Cyst
• 
  Pain (General)
• 
  Panic Attack
• 
  Parkinson's Disease (PD)
• 
  Peripheral Artery Disease (PAD)
• 
  Peptic Ulcers
• 
  Polio
• 
  Pneumonia
• 
  Post Nasal Drip
• 
  Post Traumatic Stress Disorder
• 
  Premenstrual Syndrome (PMS)
• 
  Psoriasis
• 
  Renal Failure
• 
  Restless Legs Syndrome (RLS)
• 
  Ringworm
• 
  Rosacea
• 
  Sciatica
• 
  Schizophrenia
• 
  Sinus Infection
• 
  Skin Problems/Rash
• 
  Sleep Disorders (Sleep Apnea)
• 
  Snoring
• 
  Staph Infection (MRSA)
• 
  Tuberculosis (TB)
• 
  Tuberculosis (TB)
• 
  Urinary Tract Infection (UTI)
• 
  Varicose Veins
• 
  Vertigo
• 
  Yeast Infection (Candidiasis)
• 
  Other:
  

Kerala Ayurveda

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