Medical Questionnaire for Your Ayurveda Stay

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1. About you
2. Your stay
3. Symptoms
4. Covid-19
5. Medical history
6. Daily life
7. Sleep & mind
8. Body check & submit

About you

Basic details so our team can reach you.

Please enter your Full name.

Age

Gender

Male Female Other N/A

What is your email address can we reach you? This is only to get in touch, not to send spam.

Please provide your phone number. Preferable the one with the active Whatsapp, for better communication. Choose your country code, then type your number.

Emergency Contact Preferable the one with the active Whatsapp, for better communication. Choose your country code, then type your number.

Job

How does job effect your health and mind wise?

Are you interested in medical astrology aspects?

Yes No

Country

City/Town/Village

Date of Birth

Time of Birth

Medical history

For each condition, tell us if you have it and whether it runs in your family.

Condition	You	Family History
Diabetes	Yes No
Tuberculosis	Yes No
Bronchitis	Yes No
Asthma	Yes No
Heart Disease	Yes No
Thyroid Disease	Yes No
Anemia	Yes No
Skin Disorders	Yes No
Jaundice	Yes No
Epilepsy	Yes No
Urinary Disorder	Yes No
Neurological Disease	Yes No
Kidney Disease	Yes No
Blood Disease	Yes No
Digestive Disease	Yes No
Hyper Acidity	Yes No
Hemorrhoids (piles)	Yes No
Cancer(s)	Yes No

Allergies towards, please enumerate:

Injuries

Surgeries

Your data is secured and encrypted · Never shared with third parties

Athreya Medical Questionnaire:
Tell Us About Your Health

Bowel habit

Bladder habit

Your medical questionnaire has been received

Athreya Medical Questionnaire:Tell Us About Your Health

Bowel habit

Bladder habit

Your medical questionnaire has been received

Athreya Medical Questionnaire:
Tell Us About Your Health