Ask Expert

Anyone can request an appointment with Aura Homeopathy. Please complete the form below keeping in mind that the more information you give us, the better we can handle your appointment request.

Name of the Patient *
Age *	(Yrs.)
Sex *
Weight	(Kg)
Height	(e.g. 5 feet, 7 inches)
Profession
Marital Status
Email *
Mobile *
Complete Postal Address
City
State
Zip
Country *
1. Describe your main problems for which you want to seek our advice. *
2. For how long, are you suffering from these problems ?
3. How is your physique ?	Fat Slim
4. How is your appetite ?	Good Poor
5. Do you have constipation ?	Yes No
6. Type of food that you eat.	Veg. Non-Veg.
7. Do you consume tobacco in any form ?	Yes No
8. Are you addicted to any other intoxicant (e.g., liquor/wine etc.) ?	Yes No
9. Do you take excessive quantity of tea or coffee ?	Yes No
10. Do you suffer from sleeplessness ?	Yes No
11. Do you suffer from excessive urination ?	Yes No
12. Do you feel any irritation or burning sensation while passing urine ?	Yes No
13. Do you feel palpitation of heart or pain in chest or breathlessness during physical exercise ?	Smooth Restricted
14. Are you a patient of High Blood Pressure ?*	Yes No
15, If yes, mention your blood pressure.	Systolic / Diastolic
16. Are you suffering from Diabetes ?*	Yes No
17. If yes, mention Blood Sugar	Fasting PP Random
18. Have you suffered from any disease earlier ?	Yes No
19. If yes, Name it.
20. If you have recently undergone a medical check-up pertaining to blood, urine, stool, sputum, any x-ray / ultrasonography, please mention the related reports.
21. Any other problem that you might like to state.
22. Is there a history of any hereditary disease in the family ?	Systolic / Diastolic
23. If yes, mention it.
Image	Pls upload only gif \| jpg \| png \| doc \| docx \| pdf file. Max file size 1MB.
Payment Option
Payment Method
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Manual Price	Enter amount with courier charges Rs.100/-

Ask Expert

Anyone can request an appointment with Aura Homeopathy. Please complete the form below keeping in mind that the more information you give us, the better we can handle your appointment request.

Payment Option