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Astanga Wellness Online Consultation Form
Please fill our consultation form so that we can understand your health concerns. By filling the form you certify that you are 18 years and above and take full responsibility for reaching out to us and for sharing the details in the form.
We thank you for reaching out to us. We will reply within two working days with our inputs and suggestions. We assure you of our professional services based on nearly two and a half decades of clinical experience. We speak the language of good health & life.... Dr Anta Kadagad Kembhavi & Dr Aakash Kembhavi
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Email
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Name
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Gender
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Your WhatsApp number. If you do not want to share your number you can type in 00000
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Age (in years)
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Height (in cms)
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Weight (in Kilograms)
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Country of Residence
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Main Complaints (Please write your symptoms with duration)
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Are you presently taking any treatment or medication for the complaints listed above?
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If you answered Yes to the above question, please provide details of the treatment or medication that you are taking.
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Please provide details of any illnesses or surgeries etc that you may have had since childhood. The more details you provide the better.
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Please provide details of family health history - parents & siblings.
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Provide details of your eating habits. Mention the time and what you eat for breakfast, lunch & dinner and snacks. Also add how much water do you drink per day. Include details of Alcohol intake, Smoking etc habits as well.
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Provide details of your exercise and any other physical activity routines that you follow.
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Menstrual History - age at which you had your first cycle, any form of contraception used, regularity of your cycle, any abnormalities, pregnancies etc.
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