Home Remedies assessment form July 25, 2016 Ayur Sudha Personal Information Your Name (required) Age : Gender : Address City State Postal code Country Phone no Email Height Weight Occupation Name of your Disease Chief Complaint About Your Problems Signs or Symptoms How long you are suffering from Dietary Details Your Food and life style habits Any food or weather Increase or decrease your problem Presently On Medicines Are you Suffering from any other health problem (Diabetic , Hypertension , Heart Problem , Any Other Disease etc) Appetite (Normal , Low , High) Bowel Movements ( Like Acidity , Constipation , Normal , Regular , Irregular , Other Problems Etc.) Urinary System ( Color of Urine , Frequency ,Burning Sensation ) Sleep ( Sound , Normal , Disturbed , Insomania ) Mental/ Emotional Condition ( Anxious, Nervous , Worrisome , Depressed ,Tense , Relaxed , Irritable ,Impatient , Patient , Calm ,Lethargic , Energetic, Restless ) Previous Medical History Results of that treatment How do you find us ( Google Search , YouTube , Google Ads ,FaceBook , Friend's Suggestion , Any Social Media ) Anything more you want to tell about your health problem Your Message