New Patient Registration Form

Please enter your Full name.

First NameLast Name

Age

Gender

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 communicationFormat: +00 0000000000.

Emergency Contact

Preferable the one with the active Whatsapp, for better communicationFormat: +00 0000000000.

Job

How does job effect your health and mind wise?

Are you interested in medical astrology aspects?

Country

City/Town/Village

Date of Birth

Time of Birth

Hour Minutes

AM/PM Option

Start Date

Date

End Date

Date

Specific list of symptoms bothering you the most

Which factors aggravate your symptoms?

Which factors relieve your symptoms?

Did you ever get Covid-19 positive ?

Do you suffer from any post Covid-19 Symptoms ?

If yes , please elaborate with duration

Did you get vaccinated against Covid-19 ?

Any positive side effects ?

If yes , please elaborate the symptoms faced with duration

Any negative side effects

If yes , please elaborate the symptoms faced with duration

What are your medical social expectations from a trip to Athreya?

History of current complaints/symptoms, their sequence of chronology and their duration:

History of previous aliments that bothered you in chronology

History of any Ayurvedic therapies & or any form of energy healing therapies and the duration of its effect lasting in body

Current medication that you are utilizing

Diabetes

Diabetes Family History

Tuberculosis

Tuberculosis Family History

Bronchitis

Bronchitis Family History

Asthma

Asthma Family History

Heart Disease

Heart Disease Family History

Heart Disease

Heart Disease Family History

Thyroid Disease

Thyroid Disease Family History

Anemia

Anemia Family History

Skin Disorders

Skin Disorders Disease Family History

Jaundice

Jaundice Family History

Epilepsy

Epilepsy Family History

Urinary Disorder

Urinary Disorder Family History

Neurological Disease

Neurological Disease Family History

Kidney Disease

Kidney Disease Family History

Blood Disease

Blood Disease Family History

Digestive Disease

Digestive Disease Family History

Hyper Acidity

Hyper Acidity Family History

Hemorrhoids (piles)

Hemorrhoids (piles) Family History

Cancer(s)

Cancer(s) Family History

Allergies towards, please enumerate:

Injuries

Surgeries

Daily habits – from waking up till sleeping time duration of gadgets usage – mobile, desktop, pc, etc.

Addictions to smoke, liquor, drugs any substances?

Appetite do you feel definite, timely hunger?

Involved any religious or spiritual practices, yoga, chanting of mantras, prayers, occult practices, exercise patterns

Time gap between consecutive meal time?

Quantity of water intake?

Ice cold / normal / warm water intake?

How often in a day or week do you visit toilet?

Stools float or sink in water of toilet closet?

It is satisfactory evacuation? Or Incomplete bowel evacuation?

How many seconds does the standard urination last in one session/stretch?

Incontinence of urine?

Burning sensation urine?

Non pale or dark color urine through out day?

Sweating easily or with difficult?

Foul smell to clothes by sweat?

Habit of subjecting body to high heat & severe cold temperature fluctuation in quick succession in short time span?

Any head oil used regularly?

Body shower in hot water?

Hot water for head wash?

Sleep duration (how many hours)

Day sleep habits?

Habit of postponing when sleep is demanded by body?

Feeling tired and drained even after sleeping long hours?

How many hours of sleep is needed to feel fresh?

Starting trouble in sleep?

Breaking, interruption trouble in sleep?

Are you constantly stressed?

Feel emotionally low?

Feel empty/incomplete?

Personal Family life stress?

Height

Weight

Blood pressure high or low?

Vision symptoms if any, eye sight decreasing? Duration? Using glasses?

Ear / symptoms if any, duration?

Nose/symptoms if any, duration?

Through nose can you make 10 seconds deep breathing in and breath out?

Throat symptoms if any, duration?

Dental symptoms or dental work history

Mouth symptoms if any, duration?

Do you feel bitter / sour / salty / sweet taste feeling in mouth without using any such food materials?

Do you make daily tongue cleaning?

Is the tongue with coating? Can you look in mirror?

Any cardiac history? Do you feel very breathless on climbing stairs or walking uphill?

Do you have any major scars on the body from any accident and / or surgeries?

Have you had any broken bones?

Menstrual history and present pattern, regularity, flow quantity, specific features Obstetrics history if relevant

Any Medical Documents (Optional)

I hereby declare that the information given in this application is true and correct to the best of my knowledge and belief. in case any information given in this application proves to be false or incorrect, I shall be responsible for the consequences.

Athreya Medical Questionnaire

Probable Duration of stay at Athreya

Bowel habit

Bladder habit