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Diagnosis questionaire

In order to receive a consultation, treatment options and/or quotes from Ayur Kshetra Clinic, please answer the following questions in detail and email it to diagnosis (AT) ayur-kshetra (DOT) com. Our experts will get back to you shortly.

Date:
Name:
Email:
Telephone:
Address:
Country:

Symptoms and their duration:

Sensitivities:

Food habits:

Sleep patterns:

Life style and stress levels:

Exercise patterns:

Existing medical conditions and routinely taken medication: