Paid Advice Form
Name*
Full Address: *
Ph. No.*
Email*
Gender*
Male Female
Date of Birth
Date
Month
Year
Age*
Height cms.
Weight Kg.
Education
Profession
Exercise Regularly
Note: Please answer to the questions applicable to you. Multiple options are accepted for certain questions.
1. Built:
Small Medium Stout Thin Obese
2. Change in Weight:
Regular Irregular Decreasing abnormally since last one year.
3. Working Hours:
Maintained Increasing Shift Duties
4. Work hours per day:
Less than equal 8 hrs. Greater than 8 hrs.
5. Nature of Work:
Sitting Hard Work Stress Shift Duties Traveling
6. Daily Wake Up time:
Before 6:30 am Later than 6:30 am
7. Feel energetic? :
Yes No
8. Motion / Bowel Habits:
Morning Any Time Satisfactory Unsatisfactory
9. Exercise:
Regular for more than 10 yrs. Regular for more than 5 yrs. Regular upto 1 yr.
Irregular No exercise    
10. Yoga Practice:
Regular for more than 10 yrs. Regular for more than 5 yrs. Regular upto 1 yr.
Irregular No Yoga Practice    
11. Relaxation by reading book, listening to music, singing etc.:
Fortnight Once a month No Relaxation
12. Massage:
Once a week Fortnight Once a month No Massage
13. Psyche (Intensity 1 = Minimum, Intensity 5 = Maximum)
Stress Intensity 1 2 3 4 5
                     
Anxiety Intensity 1 2 3 4 5
                     
Depression Intensity 1 2 3 4 5
                     
Anger Intensity 1 2 3 4 5
                     
Jealousy Intensity 1 2 3 4 5
14. Food intake :
With hunger Without hunger
15. Late night dinners :
Between 9 to 10 for more than 10 yrs. Between 9 to 10 for more than 5 yrs.
Between 9 to 10 for more than 1 yr. Between 10 to 11 for more than 10 yrs.
Between 10 to 11 for more than 5 yrs. Between 10 to 11 for more than 1 yr.
After 11 for more than 10 yrs. After 11 for more than 5 yrs.
After 11 for more than 1 yr. No.
16. Eat out / Restaurant visits :
Rarely (Once a month) Weekly once Weekly 3 - 4 times Daily
17. Fast food (Pizza, Burgers, Bhel, Panipuri, Chats, Pavbhajis...etc.) :
Rarely (Once a month) Weekly once Weekly 3 - 4 times Daily
18. Cold drinks :
Rarely (Once a month) Weekly once Weekly 3 - 4 times Daily
19. Incompatible food (milk + fruits e.g. fruit salad with milk, milk shakes, milk + salty bakery items, milk + sour such as cheese, Paneer etc.) :
Rarely (Once a month) Weekly once Weekly 3 - 4 times Daily
20. Curds / Yogurts :
Rarely (Once a month) Weekly once Weekly 3 - 4 times Daily
21. Fried items :
Rarely (Once a month) Weekly once Weekly 3 - 4 times Daily
22. Regular intake of milk :
Yes No
23. Liking and consumption of pure Ghee (Clarified Unsalted Butter) :
Yes No
24. Overall nature :
Happy Unhappy Satisfied Unsatisfied
Calm and quiet Anxious Hot Tempered Generous Selfish
25. Do you believe in God / Supreme power?
Yes No
26. Reaction to odd / adverse situations :
Happy Unhappy Satisfied Unsatisfied
Calm and quiet Anxious Hot Tempered Generous Selfish
27. Blood sugar level - normal? :
Yes No Do not know
28. Heredity of disease
Cancer Diabetes Heart Disease Asthma
Hypertension Thalessemia Hemophilia Skin Disease
Hyper – Acidity High Myopia
   
Any other please specify
29. History of disease since childhood :
Small Pox Chicken Pox Typhoid Mumps
Hepatitis Urinary Tract Infection Recurrent Upper Respiratory Tract Infection Diabetes
Hypertension Heart disease    
   
Any other please specify
30. Present complaints, if any :
Loss of Appetite Loss of Energy Constipation
Loose Motions Headache Sinusitis
Bronchitis Nausea
   
Any other please specify
31. Current Medication if any :
Antihypertensive Ant diabetics Antacids
Sleeping Pill Anti-anxiety Antidepressants
Pain killers Bronchodilators Inhalers
Laxatives Hormone replacement therapy Contraceptive pills
Anti hyper Hypo Thyroidism Folic Acid
Iron Calcium Vitamins
Antiemitic  
   
Any other please specify
32. Temperature at working place :
Below 24 degree Celsius Above 24 degree Celsius
33. Body directly exposed to A/C Vent? :
Yes No
34. Sitting in same place for more than 2 hrs. Continuously :
Yes No
35. Dinner before 8:30 pm? :
Yes No
36. Duration between Meals and Sleep:
37. Home food? :
Yes No
38. Suffering frequently from any of the following symptoms :
Backache Neck pain Joint pain
Recurrent Cold Cough Asthma
Indigestion Constipation Fissures
Piles Hypertension Insomnia
Any other please specify
39. Regarding Blood Pressure :
Blood pressure within normal limits
Blood pressure not within normal limits
Blood pressure not checked
40. Obstetric History : Give Details if Necessary.
Date of Last Menstrual Cycle
Date 
Month 
Year 
If Pregnant ?
Yes     No   
Expected Date of delivery
Miscarraige or Abortions if Any (How Many Times ?)
If Medical Termination of Pregnacny (How Many Times ?)
Delivery (How Many Times ?)






Copyright 2008 Garbhasanskar. All rights are reserved.