Consultation Golden knight > Consultation For consultation you can contact our competent team of Hakims and Vaids who implement and monitor the quality of our products. ENQUIRY FORM General Male Female General General Name of Patient * Email Address * Phone No. * Age (Yrs.) * Weight (Kg) Height (Feet & Inch) Profession Marital Status * Married Unmarried Postal Address City * State * PIN / Zip Code Country * Do you suffer from Hypertension? * Yes No If yes, mention your BP Are you suffering from Diabetes ? * Yes No If yes, mention Blood Sugar Level 1. Main problems * 2. For how long, are you suffering from these complaints? 3. Appetite Good Average Poor 4. Motion Normal Constipation Loose 5. Food Habit Vegetarian Non-Veg 6. Built Fat Moderate Thin 7. Do you have the problem of burning chest ? Often Sometimes Never 8. Do you suffer from headache ? Often Sometimes Never 9. Do you suffer from sleeplessness ? Often Sometimes Never 10. Do you smoke or chew tobacco ? Yes No 11. Do you drink excessive tea or coffee ? Yes No 12. Do you consume alcohol ? Yes No 13. If you have suffered from any major disease earlier, kindly do mention it here ? 14. If there is a history of any hereditary disease in your family, kindly do mention it here ? 15. If you have undergone any medical investigations, kindly mention here 16. Any other problem, which you would like to describe reCAPTCHA Submit Male General Name of Patient * Email Address * Phone No. * Age (Yrs.) * Weight (Kg) Height (Feet & Inch) Profession Marital Status * Married Unmarried Postal Address City * State * PIN / Zip Code Country * Do you suffer from Hypertension? * Yes No If yes, mention your BP Are you suffering from Diabetes ? * Yes No If yes, mention Blood Sugar Level 1. Main problems * 2. For how long, are you suffering from these complaints? 3. Appetite Good Average Poor 4. Motion Normal Constipation Loose 5. Food Habit Vegetarian Non-Veg 6. Built Fat Moderate Thin 7. Do you have the problem of burning chest ? Often Sometimes Never 8. Do you suffer from headache ? Often Sometimes Never 9. Do you suffer from sleeplessness ? Often Sometimes Never 10. Do you smoke or chew tobacco ? Yes No 11. Do you drink excessive tea or coffee ? Yes No 12. Do you consume alcohol ? Yes No 13. If you have suffered from any major disease earlier, kindly do mention it here ? 14. If there is a history of any hereditary disease in your family, kindly do mention it here ? 15. If you have undergone any medical investigations, kindly mention here 16. Any other problem, which you would like to describe reCAPTCHA Submit Female General Name of Patient * Email Address * Phone No. * Age (Yrs.) * Weight (Kg) Height (Feet & Inch) Profession Marital Status * Married Unmarried Postal Address City * State * PIN / Zip Code Country * Do you suffer from Hypertension? * Yes No If yes, mention your BP Are you suffering from Diabetes ? * Yes No If yes, mention Blood Sugar Level 1. Main problems * 2. For how long, are you suffering from these complaints? 3. Appetite Good Average Poor 4. Motion Normal Constipation Loose 5. Food Habit Vegetarian Non-Veg 6. Built Fat Moderate Thin 7. Do you have the problem of burning chest ? Often Sometimes Never 8. Do you suffer from headache ? Often Sometimes Never 9. Do you suffer from sleeplessness ? Often Sometimes Never 10. Do you smoke or chew tobacco ? Yes No 11. Do you drink excessive tea or coffee ? Yes No 12. Do you consume alcohol ? Yes No 13. If you have suffered from any major disease earlier, kindly do mention it here ? 14. If there is a history of any hereditary disease in your family, kindly do mention it here ? 15. If you have undergone any medical investigations, kindly mention here 16. Any other problem, which you would like to describe reCAPTCHA Submit
