Nilayoram Resorts & Ayurvedic Centre
Painkulam, Cheruthuruthy -679 531
Kerala, India
Ph:00 91 487 2384788 / 0091 4884 262789,
Email:nilayoram@gmail.com

PRESENTATION OF DATA FOR AYURVEDIC HEALTH ANALYSIS BY DOCTORS PANEL
To:Whom It may Concern

additional information including medical reports if relevant
History of Tick Duration
Diabetes
Heart Disease
Hypertension
Hypercholestrimia
Joint diseases
Stomach complaints
Respiratory disease
Liver disease
Skin allergy / disease
Hay Fever / Sinusitis
Eye disease
Ear disease
Hemorrhoids
Renal (kidney) diseases
Sexual weakness
Epilepsy
Giddiness
Swelling
Thyroid problems
Urinary disease
Injuries
Headache
Uterine fibroid
Ovarian cyst
Intestinal disease
Numbness
Gas accumulation
Any other previous illness





Are you currently taking any medication?
If yes, give particulars with dosage:
Food items you are allergic to and reaction:
Food items you avoid and why:
Food cravings:
Do you usually / occasionally / frequently get bloating
/ gas / cramps after eating / when you do not eat properly /
even when you eat properly?
Other important symptoms you have noticed related to your digestion are:

Recent Blood Test Results








































Use this section only if you are female