Consult Doctor| Ayusmat Naturopathy & Yoga Hospital

Name

Sex
Male Female Other

Age

Phone

1.) Are you visiting for a Detoxification and Rejuvenation?
Yes No

2.) List out specific symptoms bothering you the most?

3.) What are the factors that aggravate your symptoms? For example: Do changes in weather conditions increase pain in joints? Does stress change your symptoms?

4.) What are the factors that alleviate your symptoms? For example: A complete rest provides lower back pain relief. Exercise makes body feel lighter.

5.) What are your expectations from Ayusmat?

6.) What is the nature of your job? How does it affect your health, mind and body?

7.) Could you share with us about your personal life and how it affects your mental psyche?

8.) Do you have a history of Naturopathic treatment or any form of energy healing therapies and the duration of its effect on you?

9.) Are you on any medication currently? If so, list it.

10.) What is your daily routine? (From Waking up till sleeping)