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Medical Questionnaire

RESERVATION

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Please fill in the medical questionnaire to share your medical details with the vaidyas in SDJ to help them understand your problem.


Questionnaire Form

Chief Complaints
Complaint
Since: years/ months/weeks/days
 

Personal Informations


Diet
Are you Vegetarian or a Non vegetarian?
Bowel Evacuations

List the Current Medications that you take ( allopathy ):

Name Of The Medicine
Method Of Intake
Suggested For
Medicine
Write either the generic name or Brand name with mg
The way in which it is taken. Example - one tablet twice daily after food
Medical conditions for which it is suggested
 
Treatment History ( Information about various treatments underwent for the illnesses ):

Treatment History (Information about various treatments underwent for the illnesses):
Name Of The Treatmets
Underwent During
Special note (if any)
 

Gynaecological History


MM slash DD slash YYYY

Obstretric History


Please bring all the old medical records when you come.

Contact Us

SDJ Ayurvedalaya
Opposite to PSG Gardens, Anaikatti, Coimbatore- 641108, Tamilnadu, India.
+91 422 2657222
+91 9442241600
+91 96552 81034
[email protected]
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In short It is an “aalaya” or “a temple” where one can experience the authentic and traditional practice of Ayurveda in a picturesque environment.
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