Full Name *

Date of birth *

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What is your Profession? *

What does your daily lifestyle look like? (Include Work and Home) *

What is your Gender? *

Female

Male

Medical Condition which you would like help with? (Eg. Asthma, Diabetes, Anxiety, Digestive Problems, Pain in Specific Body Parts) Please elaborate as much as possible to help us understand your situation. *

How long have you been suffering with your medical condition? *

Are you on any regular medication? *

Do you have any other past medical history? *

Have you ever had any surgeries done? If yes, please explain *

What meals do you try and eat in a day? *

Breakfast, Lunch, Dinner

Brunch and Dinner

Breakfast and Dinner

Breakfast and Lunch

What time is your first meal in the day? *

What time is your last meal for the day? *

Do you eat snacks through your day? *

What do you eat on a daily basis? (Breakfast, Lunch, Dinner and Snacks) Answer as best as you can *

Do you eat cooked or raw vegetables? How often? *

How often do you eat baked food? *

How often do you eat refined flour foods? *

Do you eat food or snacks when you are not hungry? *

What time do you wake up? *

What time do you sleep? *

Do you sleep during the day? If yes, how long? *

Do you fall asleep after eating food? *

Do you experience stiffness in your joints, particularly when you wake up? *

How often do you do a stool? *

Do you feel bloated straight after eating or do you need to poop straight after eating? *

What does your stool look like? *

Do you think you have gas or acidity issues? (Is it hard to pass gas) *

How often do you need to urinate? *

What is the color of your urine? *

What does your urine smell like? *

Do you go to the gym? If yes, how often? *

Do you have a stressful lifestyle? If yes, please explain *

Do you drink alcohol? If yes, how often?

Do you smoke? If yes, how often?

How is the weather where you are located? *

What is your preference or showering/bathing? *

Would you like to send us a copy of your medical history and blood test results (if available)? (This would be good for our Drs to view but is not essential) *

You acknowledge that:

We are here to provide information about ayurvedic methods that may or may not help your life but consult with your GP for advice on implementing methods.
We hold the right to refuse a referral based on age, insufficient information or if we are running on overload.
We are not liable for any type of losses.

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