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Shruti Ayurved Panchakarma Speciality Clinic,
17 Blue Hill, Aamchi Colony, NDA-Pashan Road, Bavdhan, Pune, Maharastra (India)
Pin - 411021

Phone :  (0091)-20-22951850
Email : info@ayurvedabliss.com

 

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1) Are you happy about your health & life ?   Yes      No
2) How long you had the Chronic Conditions about you are consulting?  
    - Briefly describe the conditions  
3) Has a doctor confirmed your diagnosis?
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   - If yes, describe his findings  
4) Have you ever been hospitalized for this condition?   Yes      No
   a) If yes, how many times ?
       - Describe reasons
   b) Have you had surgery for your Condition?  Yes     No
      - If yes, which procedure ?
5) Is there a family history of this disease ?
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6) How severe are your symptoms?
7) How has the disease progressed  since it began ?
8) Are you currently under care of- 
9) Are you currently taking medication?  Yes        No
  -If yes, list the name of medication
10) Are you allergic to any drugs, foods or other substances ? Yes      No
 - If yes, which?
11) What is your doctor's opinion about prognosis of your disease?
12) Is your sleep disturbed by the symptoms of your disease?
13) To what extent do your symptoms interfere with your daily activities?
14) How often are you having pain  or discomfort?
15) How long does the pain or discomfort last on the average?
16) How would you rate your energy level?
 		 
(1 -very low, 5 - average, 10 - very high)
17) How do you generally feel on arising in the morning?
18) Please indicate whether you have any of the given symptoms
19) Do you have any of the following disease?