Avail one Free Consultation..

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by Homeomantra

Email *

Name *

Mobile no. *

Date of birth *

YYYY

Please fill your Age *

25 yrs -30 yrs

31 yrs-40yrs

41 yrs-50 yrs

51 yrs - 60 yrs

61 years and above

Please fill up your Height in cms *

Please fill up your weight in kgs *

Health is in your hands

Agree

Disagree

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Have you faced any health issue in the past 12 months due to any of the following

Acute Infections

Deficiency disorders

Chronic diseases (High B P , Diabetes etc )

None

Over the past 12 months, have you suffered, or have you been diagnosed with, any of the following health problems? *

Upper respiratory tract infections

Asthma

Bronchitis

Allergies

Stress problems

Cardiac problems

Diabetes

PCOD

Hypertension

Digestive Problems

Cancer

Lumbar diseases

Thyroid Dysfunction

Others

None

Required

(Family Background) Has anyone in your family suffered from *

Respiratory diseases

Asthma

Bronchitis

Cardiac problems

Diabetes

Cancer

Hypertension

Others

None

Required

Are you conscious about your health?

Conscious than your circle of people

As conscious as your circle of people

Less conscious than your circle of people

Clear selection

Are you suffering from menstrual disorders? *

Yes

Are you suffering from hair fall or thinning hair?

Yes

Clear selection

Are you suffering from severe acne?

Yes

Clear selection

Are you finding difficulty in losing weight ?

Yes

Clear selection

Do you want a free consultation for your loved ones too? If 'yes' , please share their contact details with name and relationship

Thank you for your time...You will get a call from our end within 24 -48hrs.

Send me a copy of my responses.

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