Please send the following information on your each patient
separately, duly completed, via email to
yogasale@gmail.com for
record/ statistical purposes.
(Please "Copy & Paste" this form in you Email browser; then fill it
up & send to:
yogasale@gmail.com )
All personal information shall be kept strictly confidential. We do
not share your email IDs with anyone. ::
Case Record Sheet for Online Counselling:-
The answers to any questions, like name & other inconvenient/
irrelevant questions of personal nature, my be left blank, as it is
optional, but give all information to unserstand Patient Medical/
Mental condition.
===================================================
Name ::
Gender :: Male/ Female
Age ::
Marital Status ::
Blood Pressure - Mention reading, if not normal::
Sugar Level - Mention reading, if not normal::
Cholesterol Level - Mention reading, if not normal::
Weight in Kg .only ::
Height in Feet, Inches ::
Are you Overweight/ Under weight/ Normal? ::
Are you a Vegetarian/ Non-Vegetarian? ::
Dependence on Alcohol Drugs Smoking Coffee/Tea ::
Major Ailment/s or Disease/s ::
All other Ailments - in order of severity ::
Presently taking treatment for which Disease/s ::
Personal Medical History ::
Personal Mental Tension/s, if any::
Family Madical History, in brief - Parents only ::
Do your disease symptoms decrease or increase, when you change
places having different climates? ::
Give details about your addictions/cravings, if any, like tea,
coffee, alcohol, sugar, smoking, drugs etc. ::
How would you describe yourself emotionally? ::
What time do you usually go to sleep & wake up? ::
Why do you want to try Yoga Pranayama & Ayurveda Treatment? ::
Other information which you think might be helpful ::
Laboratory Investigation Reports (if any) - Please mention in brief
in text only::
USG/MRI/Scan Reports (if any) - Please mention in brief in text only
::
Remarks, if any ::
Patient Contact Information ::
Full Postal Address ::
City & ZIP/ PIN Code ::
State ::
Country ::
Home/ Landline Telephone: (Country Code - Area Code - Phone ) ::
Mobile / Cellular Phone: (Country Code - Area Code - Phone ) ::
Education ::
Email ID ::
Alternate Email ID, if any ::
Profession/ Job Role ::
For Free PC to PC calls to us, get your Skype ID FREE, (visit
www.Skype.com to
get your ID) ::
Senders' Name & Contact Information, as above, if diffenrent ::
======================================================
Hope you have first visited
www.YogPranayam.com for
more information on your Diseases/ Ailments & its treatment already
available online.
Please first visit
www.YogPranayam.com &
search very carefully for more information on your specific
Diseases/ Ailments etc. and its complete package for treatment,
with Aurvedic Herbal Medicines & VCDs/ DVDs on specific Yoga
Pranayama regimen to cure your disease/s.
Patients must visit the following pages, to get the proper
treatment for your medical/ mental condition/s.
For Package For various Diseases- Complete prescriptions of
Ayurvedic Medicines from Swami Ramdev's D Y M Trust, please search
for your specific disease online at:
Please order the medicines, which are listed on our website online
& get back to us for the rest, we shall send you the online
Invoice for the same, via the secured payment gateway.
Please get back to us on phone as per our Contact us page, if
there is any ordering or payment hassle.
For counselling, any clarifications etc. please call our customer
care, during our timings, per our Contact us page.
Calls from NGOs, Medical Professionals, friends, relatives &
associates of the affected people are welcome.
Callers identity is kept strictly confidential.
