Ayurveda Online

The Patients seeking guidance and desiring to get Ayurved Medicines should send this form duly filled in. For correspondence and remittance of M.O, Cheque, Draft, B.P.O.

Please note the following name and address.

Shri Bhuvaneshwari Aushadhashram

Gondal- 360 311 Gujarat - India

Please provide the following contact information:

Name

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country

Work Phone

Home Phone

E-mail
Please identify and describe yourself:

Age Height

Sex Male Female Weight

If married how many issues
Age of Last Child

Description of present symptoms & its duration?
Are you suffering from constipation?

Yes No
Are there any complaint about sleep or appetite

Yes No
Habit or addiction
Opinion given by the doctor or Physician (Vaidya) regarding your disease?
What is your favorite taste?
Are you performing any exercise ? What ?
Are you on any long medical therapy? Give Brief ?
Any Complaint about Menstruation in case of Female patient?
Any additional complaint or detail about your disease?
Latest information about Blood pressure and other Laboratory
investigation?
Other information?

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