Name* :     Address* :     Country* :     E-mail* :     Telephone* :     Age* :     Sex* :   ---select--- Male Female   Nationality* :     Profession * :     Marital Status* :   ---select--- Single Married Widower   Children* :   ---select--- 1 2 3 4 5 6   Symptoms/Diseases* :     Duration* :     History of present illness:     Under any medication (Give details):     History of past illness:     Medical diagnosis:     Investigation reports:     Do you experience any side effects with present medication?:     Do you wish to try Ayurveda, Why?:     Diet and habits:     Hereditary factor:     Other health problems any:     Discomfort with any food item?:     Body strength:     Body built:     Exercise regime:     Urine and stool:     Sleep:     Are you uncomfortable in any weather condition?:     Menstruation:     Other messages: