Enquiry Form

Online Consultation

Thank you for your enquiry . . .
In order to ensure that we have a thorough understanding of your problem from an Ayurvedic perspective, please ensure that you give us detailed and accurate information
Thank you


First Name
Gender Male Female
Ethnic Group  
Country of Birth
Birth Date


Prime Complaint  
Since when (Duration)  


Brief History of Disease / Complaint
Other Complaints  
How did it start?  
Where (body part & country) it started?  
When & how does it get aggravated?
When & how does it get alleviated?
What have you done for it?
Is there any proper Diagnosis. If so what is it?
Are you on any medication for it?
Have you ever taken Ayurvedic treatment for it?


Brief History of your Health from Birth
How was your birth? Normal Caesarean
How was your health during childhood?
Any major illness? (If yes what treatment was taken?)
Any other thing related to your health that you would like to mention?
Currently are you on any other medication?
Does anyone from your father’s or mother’s side or siblings or grand parents’ side
suffer or ever suffered from same complaints / illness &/or any other major

Vegetarian/Non Vegetarian/Vegan
Non Vegetarian Vegetarian Vegan
Your daily brief routine or schedule?
Your diet
What you eat?
Frequency per week?


How is your appetite?
(Good/ Moderate/ Low/ Bad)

What do you think of your digestion?
(Good/ Moderate/ Low)

How much water do you take during day?
How are your bowels?
Regular / Irregular
Feeling empty & light / Not really
Quantity (Heavy / Moderate / Low)
No of times per day
Quality (Well formed / Dry hard / Semi solid / Watery / Sticky)
Duration (Takes a while / Easy release)
Smell (Normal / Foul)

How is your urination?
Do you get the burps? If yes how are they, clear or with food taste or with reflux?
Do you feel ‘hungry’?
Do you pass wind? If yes, how often and is it smelly?
Do you get ‘Bloated’ or ‘Gurgling’ in the abdomen?
If you ‘eat’ again after eating, how do you feel?
If you don’t eat, how do you feel? Do you sustain hunger?
How is your sleep and sleep pattern? Do you feel fresh when you wake up?
How is your ‘Mind’? e.g. Hyper Active, Quiet etc.
How do you manage ‘Stress’?
How do you express yourself?
(Properly / Not totally / Incorrectly / Hide & suppress feelings)

What is your energy level?
Do you exercise regularly?
How is your social life? Are you an active participant or passive?
How is your relationship with your partner & friends?
(e.g. Open & Interactive, Excellent)

How is your ‘Sex Drive’?
What is your ‘Menstrual cycle’ History?
(e.g. Regular-Irregular, Painful etc.).

Do you drink alcohol? If yes, then how many times and how much per week?
Do you go to pubs etc? If yes how many times per

Do you smoke? If yes, then how many per day?
Do you take any drugs? If yes, what are they and how many times a day or week?
Do you take coffee or tea? If yes, which drink and how many cups per day?
Do you have any allergies? If yes, since when and what have you done for them?
Latest Laboratory reports etc. if any?
Anything else you would like to tell us?


The information offered on this site in no manner whatsoever is intended to replace the services of an authorised health practitioner in the diagnosis or medication of disease. Any application of the information or consultation on this site is at the reader's discretion and it is his/her own responsibility. For your ongoing medical ailments or health disorders please consult your local Ayurvedic physician &/or Medical doctor.