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Free Online Ayurvedic Consultation

Dr. Rama Prasad will assess your needs and suggest the best resort, treatments and time period for your health retreat. We endeavour to reply within 48 hours.

Please fill out the form below and click to send at the end.


with Ayurvedic physician Rama Prasad BAMS

Ayurveda Elements
17 Orchard Rd
NSW 2067
Ph/fax: 00 61 2 9904 7754

READ this carefully once and then fill out.
All information is kept strictly confidential.

Please attach additional information including medical reports and email a photo of the tongue if possible.

Date of birth:
Time of birth:
Place of birth:
Daytime phone:
Phone number:
Marital status:
Number of children with their age :
Height in cms/feet & inches :
Weight in stone/kilos :
Time period you can stay in an Ayurvedic retreat (give dates if possible):
Main aim in visiting an Ayurvedic retreat:
Maximum price per day (includes food, treatment, accommodation):
Visiting alone or with company:
Detail previous visits to India or an Ayurvedic centre:
Diagnosed conditions if any:
Present health concerns and symptoms:
Present medications and treatments if any:
Present health supplements if any:
Past surgeries (include terminations for women):
Hospitalisations you have had:
Accidents you have had:
Other major past illnesses:
Previous long term medication:
Previous healing systems tried:
Detail mental or physical conditions your mother/ father/ grandparents/ sisters/ brothers suffer/ suffered from:
Food items you are allergic to and reaction:
Food items you avoid and why:
Food cravings:
Recreational drug use (include alcohol, cigarettes):
The season/s you prefer:
The weather in which you feel really uncomfortable:
The time of the day you are energetic and positive:
The time of the day you are tired:
Are you vegan/vegetarian/non-vegetarian:
Do you feel hungry:
If food is delayed / missed - do you get a headache /stomach cramps / cloudy thinking / agitated /spaced out / acidic reflex / burning sensation in tummy / weakness / nausea / lighter / energetic:
After eating do you feel:
Do you usually / occasionally / frequently get bloating / gas / cramps after eating / when you don't eat properly / even when you eat properly:
Other important symptoms you have noticed related to your digestion are:
Do you clear your bowels pass: a day
Do your stools sometimes / usually - float / sink and are formed / unformed:
Do you sometimes / occasionally / get /blood / mucus / undigested food in your stool:
Are you prone to diarrhea /constipation whenever there is an emotional stress or when you eat unsuitable foods:
Number of times you urinate per day and night:
Is your urine yellow /brownish / reddish/ often or occasionally:
Is your sleep generally:
Your usual bed time:
Do you feel: in the morning when you wake up
Do you sweat:
Do you exercise regularly / rarely / occasionally / frequently for so many hours a week:
Spiritual practices you observe regularly:
Is your energy level good in the morning /midmorning /afternoon /evening:

Slowly I am:

Problems with other systems such as the following:
Nose, Smell, Ear, Hearing, Eyes, Vision, Skin, Hair,
Neuromuscular, Libido/sexuality, Emotions,Weight, Hair, Skin, Pain anywhere, Gas:
Do you tend to get any of the following:
Heart burn, mouth ulcers, dandruff, skin rashes, acidic burping, bleeding gums, cold fingers/toes, cramps, numbness:
Any other important information regarding your health:
Use this section only if you are female.
Have you had caesarians?
Are your menstrual periods regular?
Do you get PMT?
Do you get clots?
Do you get cramps?
Do you get extreme fatigue?
Details of miscarriages:
If you have been trying to fall pregnant, for how long?

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