Kailas Ayurveda Consultation

Please fill in the form below to get a customised Ayurveda Consultation specially prepared by the expert panel of doctors at Kailas Ayurveda, Kovalam.


Personal Details

First Name

Middle name

Last Name

Address

Nationality

Date on birth

Height (cm)

Weight (kg)

Sex

Profession

Occupation

E-mail address

Telephone #

Fax #

Marital status

Children

Present Illness

Symptoms with duration

Past History – Disease & Treatment

Symptoms with duration & Treatments taken
Details of Previous Diagnosis (if any)
Details of Previous Investigations (if any)

Do you have any of the following? If yes details

Diabetes Mellitus
High BP
Allergies

Family history of any disease

On any medication? Details (Dose, How Long etc.)

Personal History

Sleep
Appetite
Bowel Habits
Urination
Addicted to Tobacco / Alcohol / Drugs
Present diet -Veg/ Non Veg/ Mixed
Menstrual History