Complimentary Doctor Consultation Request Your Information First Name * Last Name * Age * Date of Birth * Father/Spouse name Gender * Height (in cms) Weight (in kgs) * Blood group Occupation Marital status * Mobile Number * Email * Address City * Next All About Your Health Do you have any health issues? * YesNo List your health issues List your current Medications / Supplements 1) Have you undergone any surgery in recent years? * YesNo If yes, please give details: 2) Are you suffering from any infectious disease or skin disease? * YesNo If yes, please give details: 3) Are you suffering from any heart disease or have undergone angioplasty/bypass/open heart surgery? * YesNo If yes, please give details: 4) Do you have any past/present history of psychiatric medication/intervention? * YesNo If yes, please give details: 5) Are you suffering from any kind of kidney/ liver/ lung disease? * YesNo If yes, please give details: 6) Did you have any episodes of seizure/epilepsy in the past 5 years? * YesNo If yes, please give details: 7) Do you suffer from any type of hernia? * YesNo If yes, please give details: 8) Are you physically or visually disabled in anyway? * YesNo If yes, please give details: 9) Can you walk 1 Kilometre without support? * YesNo If No, please specify: 10) Are you suffering from any allergies? * FoodMedicinesExternal allergiesNone Please explain in detail: 11) Have you become reliant on any of the below substances? * TeaCoffeeSmokingAlcoholZardaDrugsPaan masalaSubstanceE-cigarettesTobaccoSugarNone PreviousNext Visit Details 12) Purpose of your visit to trē wellness? * ExperienceDetoxHealingDe-StressRejuvenationLifestyle managementDisease ManagementPreventive Care 13) Preferred days for your stay at Tre Wellness * From * To * 14) Have you been to any other naturopathy / ayurveda / wellness centre before? * YesNo If yes, please mention name and duration of stay 15) When would you like to schedule doctor consultation? * Date Time ( Select Only 02:00 PM To 07:00PM ) Previous
