GADGIL AYURVEDA

Express Health Check Up

All Fields are Mandatory Fields except menstrual history

Select Your Country :

Select State :

City / District :
Full Name :

Address :
Email :

Mobile :

Phone :
Fax :

Birthdate :

Age :

Gender :

Weight In KG :

Height In CM :



HEALTH RECORD :



1) 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


2) Change In Weight :

3) Working Hours :

4) 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

5) Feel Energetic ? :

6) Yoga Practice :

7) Wakeup Timing :

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

9) 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

10) Exercise :

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

12) Massage :

13) 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

14) Tobacco :

15) Smoking :

16) Successfully deaddicated from the addictions :

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

18) Home Food ? :


19) Breakfast :


20) Food Timings :

21) Lunch Timings :

22) Dinner Before 08.30 PM ? :



23) Late Night Dinner :

24) Hotelling :

25) Junk Food :

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

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

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

29) 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.) :

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

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

32) 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

33) Fruits With Curd / Yogurt :


34) Fried Food :

35) 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. :

36) Soft / Areated / Cold Drinks :

37) 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

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

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

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

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

42) Sexual Life :


43) Sexual Intercourse Frequency :


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

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

46) Reaction to Odd / Adverse situations :

47) Temperament :

48) Psyche / Stress (Select Intensity) :

49) Habit of comparison / competition with others :

50) Feel inferior / superior / jealous :

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

52) Worship / Prayer :

53) Menstrual Cycle Details :

M.C. Started :


54) 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

55) Blood Sugar Normal ? :

56) Lipid / Cholesterol Normal ? :

57) Liver Function Test Normal ? :

58) Cardiac / Heart Investigations Normal ? :

59) 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

60) 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

61) 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

62) 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

63) Current Medication For :
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64) Suffering from any other Symptoms :

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

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

67) Availing guidance from support group :

68) Diabetes / BSL under control :

69) Onset of diabetes :

70) 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

71) Suffered from heart attack: :

72) Undergone :

73) Regarding Blood Pressure :

74) Regarding ECG :

75) Regarding Stress test :

76) Regarding Angiography :

77) Hard drink (Liquor / Alcohol) :

78) Psychological shock upto 1 yr :


Type The Verification Code * :





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