Gadgil Ayurveda

Express Health Meter

IMPORTANT :

This is NOT Online Consultation Form. With this form submission, we will only guide you for Lifestyle Modifications For Healthy Life....
No Medicines will be suggested or prescribed via this form reply.
No Online Medicines are for Selling on this website. This website is for creating awareness for Cancer, Heart Disease and Diabetes only.
As This form submission is free of cost, we can not gurantee you immediate reply from our end but we can assure that we will revert back to you as early as possible...

* All Fields are Mandatory Fields except menstrual history

1) Select Your Country :

2) Select State :

3) City / District :

4) Full Name :

5) Address :

6) Email :

7) Mobile :

8) Birthdate :

9) Age :

10) Gender :

11) Weight In KG :

12) Height In CM :

HEALTH RECORD :

13) Select Questionnaire Catagary : You Can Select Multiple Choices. Hold down the Ctrl (windows) / Command (Mac) button to select multiple options. You Can Select Multiple Choices

14) Change In Weight :

15) Working Hours :

16) Nature Of Work : You Can Select Multiple Choices. Hold down the Ctrl (windows) / Command (Mac) button to select multiple options. You Can Select Multiple Choices

17) Feel Energetic ? :

18) Yoga Practice :

19) Wakeup Timing :

20) Motion / Defecation : You Can Select Multiple Choices. Hold down the Ctrl (windows) / Command (Mac) button to select multiple options. You Can Select Multiple Choices

21) Habbits Associated With Motion / Defecation : You Can Select Multiple Choices. Hold down the Ctrl (windows) / Command (Mac) button to select multiple options. You Can Select Multiple Choices

22) Exercise :

23) Relaxation by reading book, listening to music, singing etc. :

24) Massage :

25) Addiction If Any : You Can Select Multiple Choices. Hold down the Ctrl (windows) / Command (Mac) button to select multiple options. You Can Select Multiple Choices

26) Tobacco :

27) Smoking :

28) Successfully deaddicated from the addictions :

29) Food Intake : You Can Select Multiple Choices. Hold down the Ctrl (windows) / Command (Mac) button to select multiple options. You Can Select Multiple Choices

30) Home Food ? :

31) Breakfast :

32) Food Timings :

33) Lunch Timings :

34) Dinner Before 08.30 PM ? :

35) Late Night Dinner :

36) Hotelling :

37) Junk Food :

38) Excessive consumption of sweet taste (E.g. Jam, jelly, sugar, jaggery, molass, chocolates, icecreams, cakes, pastries, desserts etc.) :

39) Excessive consumption of sour food (tomato, tamarind, curds, yoghurt, buttermilk, citrus fruits, vinegar, pickles etc.) :

40) Excessive salty (Extra table salt, pickles, salty items like potato chips, cashewnuts, peanuts etc., cheese, butter etc.) :

41) Excessive consumption of Pungent taste (E.g. chillies, garlic, capsicum / bell peppers, ginger, mint, chillie sauce, tomato sauce, various spices like cinnamon, black pepper corns etc.) :

42) Excessive consumption of Bitter taste (E.g. Bitter gourd, neem, fenugreek etc.) :

43) Excessive consumption of Astringent taste (E.g. Brinjal/aubergines/eggplant, spinach, betelnut, etc.) :

44) Non-vegetarian Diet : You Can Select Multiple Choices. Hold down the Ctrl (windows) / Command (Mac) button to select multiple options. You Can Select Multiple Choices

45) Fruits With Curd / Yogurt :

46) Fried Food :

47) Incompatible food (Milk+fish, Chicken+curd/yogurt, Milk + Fruits (fruit salad with milk/ icecream, milkshakes), Milk + Salty items (biscuits, puffs, toast, khakra) , Milk + Sour items such as Cheese, Paneer etc.) or combination of Milk & curds/yogurt/butter milk etc. :

48) Soft / Areated / Cold Drinks :

49) Oil For Cooking : You Can Select Multiple Choices. Hold down the Ctrl (windows) / Command (Mac) button to select multiple options. You Can Select Multiple Choices

50) Food for Religious Fast with potato, sago, varai etc :

51) Body directly exposed to A/C Vent? :

52) Temperature at working place (Those working in Airconditioned atmosphere should attempt) :

53) Sitting in same place for more than 2 hrs. continuously? (Those with sedentary lifestyle should attempt) :

54) Sexual Life :

55) Sexual Intercourse Frequency :

56) Overall Nature : You Can Select Multiple Choices. Hold down the Ctrl (windows) / Command (Mac) button to select multiple options. You Can Select Multiple Choices

57) If life is unsatisfied, do you make any efforts for satisfaction :

58) Reaction to Odd / Adverse situations :

59) Temperament :

60) Psyche / Stress (Select Intensity) :

61) Habit of comparison / competition with others :

62) Feel inferior / superior / jealous :

63) Do you believe in God / Supreme power? :

64) Worship / Prayer :

65) Menstrual Cycle Details : M.C. Started :

66) More About Menstrual Cycle : You Can Select Multiple Choices. Hold down the Ctrl (windows) / Command (Mac) button to select multiple options. You Can Select Multiple Choices

67) Blood Sugar Normal ? :

68) Lipid / Cholesterol Normal ? :

69) Liver Function Test Normal ? :

70) Cardiac / Heart Investigations Normal ? :

71) Frequently Suffering From Any Of Symptoms ? : You Can Select Multiple Choices. Hold down the Ctrl (windows) / Command (Mac) button to select multiple options. You Can Select Multiple Choices

72) Presently Suffering From : You Can Select Multiple Choices. Hold down the Ctrl (windows) / Command (Mac) button to select multiple options. You Can Select Multiple Choices

73) History of Diseases since childhood : You Can Select Multiple Choices. Hold down the Ctrl (windows) / Command (Mac) button to select multiple options. You Can Select Multiple Choices

74) Present Complaints If Any : You Can Select Multiple Choices. Hold down the Ctrl (windows) / Command (Mac) button to select multiple options. You Can Select Multiple Choices

75) Current Medication For : You Can Select Multiple Choices. Hold down the Ctrl (windows) / Command (Mac) button to select multiple options. You Can Select Multiple Choices

76) Suffering from any other Symptoms :

77) Currently suffering from Cancer for the 1st time / primary onset and Under Rx like chemotherapy / Surgery / Radiation :

78) History of Cancer but currently not suffering from Cancer diesease free stage :

79) Availing guidance from support group :

80) Diabetes / BSL under control :

81) Onset of diabetes :

82) Currently suffering from diabetic complaints like : You Can Select Multiple Choices. Hold down the Ctrl (windows) / Command (Mac) button to select multiple options. You Can Select Multiple Choices

83) Suffered from heart attack: :

84) Undergone :

85) Regarding Blood Pressure :

86) Regarding ECG :

87) Regarding Stress test :

88) Regarding Angiography :

89) Hard drink (Liquor / Alcohol) :

90) Psychological shock upto 1 yr :

Type The Verification Code * :