5/25/2020 Health Questionnaire

Health Questionnaire
Please fill all the details

Guest Name *

AJAY MISTRY

Contact No. *

7506869705

Email Id *

ajay.cg.mistry@gmail.com

City *

VADODARA

Age *

54

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5/25/2020 Health Questionnaire

Gender *

Female

Male

Other:

Date of Consultation *

MM DD YYYY

05 / 25 / 2020

Height *
In cms

176

Weight(in KG) *

81

Profession *

General Management, Engineering Service

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5/25/2020 Health Questionnaire

Have you attended AOL Happiness Program? *

Yes

No

Diet *

Normal Vegetarian

Appetite *

Good

Less

Dont feel hungry

Bowels *

Twice a day

Once a Day

Once in 2-3 days

Once in more than 3 days

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5/25/2020 Health Questionnaire

Urination *

Light Yellow

Dark Yellow

Brown

Redish

Sleep *

Sound Sleep

Not able to sleep

Current Health Complaints *

1) Profound hearing loss in the Right Ear since Nov-2018. Also, continuous tinnitus sound in this ear
since then. It is sudden hearing loss after vertigo and vomiting.
2) One of the nostril always remain blocked, which creates breathlessness during sudarshan kriya
(learnt at Sri Sri Vasad Ashram).
I am attaching following 3 reports a) aleopathic treatment, 2) Planet Ayurveda, 3) Sri Sri Vasad Ashram
nadi parixan

History of Surgery *

Appendices, in 1986

Running Medication *

Ayurveda (AUGI capsules, 2 capsules with lukewarm water half hr after meal twice a day & AUGI Karna
Oil drops in both ears) suggested by one of the practitioner.

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5/25/2020 Health Questionnaire

Covid-19 related history in family *

NO

Disease History in the family *

Father - High Blood Pressure, Mother - Diabetic

Upload Reports

Hearing Treatme…

This form was created inside of Sri Sri Tattva.

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