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Home
about us
Treatments
Diabetes
Sexology
Other Diseases
Treatment Methods
Products
Life Problems
FAQ
siddha System
Contact us
Contact us
Payment Mode
To Get Appointment
Patient Details
English
Arabic
Bengali
English
French
Hindi
Tamil
Telugu
Details Required to Heal You
1. Full Name
*
Your Recent Photograph
Upload your photo in following link
https://forms.gle/bCFVY6gdbL3VFx3F6
2. Date of Birth
3. Gender
*
Male
Female
Other
4. Full Address
5. Email
*
6. Mobile Number
*
7. Place of Living
*
8. Religion
9. Marital status
Married
Unmarried
10. Occupation
*
11. Does your profession have day and night shift system?
*
Day Shift
Night Shift
Day and Night Shift
12. Personal History
a ) Height [in cm]
b) Weight [in Kg]
c) Appetite
d) Sleep
e) Bowl Movement
f) Urination
13. Blood Pressure:
14. Sugar Level
15. Enter Your Problems / Diseases in one by one with duration of suffering
1 ) Problem / Diseases - Duration
2 ) Problem / Diseases - Duration
3 ) Problem / Diseases - Duration
4 ) Problem / Diseases - Duration
5 ) Problem / Diseases - Duration
6 ) Problem / Diseases - Duration
7 ) Problem / Diseases - Duration
Enter Your Problems / Diseases in one by one with duration.
Example :
1. I have a sugar Complaint - 2 years
2. I have a Low BP Complaint - 4 years
16. Menses Condition Details (in case of women)
17. Do you Suffer from any type of Hernia?
18. Have you suffered with heart ailment in the Past? (please give full detail)
19. Please tick your Habits:
Tea
Cofffe
Smoking
Taking Alcohol
Drug Addiction
19. (a) Any Other Habits, Please Specify
20. Can you walk 1 Km without any Support? (If can't, give detail why?)
21. Details of the operations undergone (specify the year also)
22. What medicines you are taking at present for your ailments?
23. Your Food Habits?
Veg
Non Veg
23. a) Your favorite Foods ?
24. Do you practice daily any kind of Yoga, Pranayama, Nadi Suthi or Physical exercises etc...?
Yes
No
25. Have you suffering from Diabetes Complaints, if so, please give the details.
26. Does your blood have HIV?
*
No
(IF YES please Send HIV Test report to contact@DoctorElango.com)
27. Are you using any temporary contraceptive method while having sexual intercourse?
28. Have you masturbation habit earlier or now ? If yes, How many years ?
29. Are you suffering from any Psychological disorder?
30. Are you suffering from Extreme worries, Fears, Anxieties, Confusions, Severe Difficulties of life, Marital Life Problems or Friend ?
31. Have you personal problems of any nature which you hesitate to discuss with your life partner (or) family member (or) friend ? ( if so, please give full details )
32. Are you wearing any Gems (or) Precious stones in any of your ornaments, for any medical value ( or ) for best lucks ? ( if so, please give full details)
33.Have you infected by Covid-19?
No
Yes
34. Have Covid-19 vaccinated, please give details.
35. Do you want to inform us any more things?
36. Why do you prefer Our Natural Healing System ?
37. How did you know about the services and address of our Doctor Elango Ayush Hospital ?
DECLARATION
*
I hereby declare that the photographs, information and other reports given in this application are absolutely true to the best of my knowledge. I Request you to please give me remedies and treatments to get relief.
Name
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