Your Full Name *

Your Email Address *

Your Phone Number *0 / 10

Choose Gender *MaleFemale

Are you over the age of 60? *YesNo

Are you suffering from recurrent Attack of Allergies? Do you have Fever, Sore Throat, Cough, Cold, Sneezing or Headache? *YesNo

Do you suffer from recurrent Stomach, Intestinal and Bowel Disorders? *YesNo

Are you suffering from Chronic Illnesses like Thyroid/ Psoriasis/ White Patches/ Eczema/ Lichen Planus or any Autoimmune Disorder? *YesNo

Are you suffering from Diabetes/ Blood Pressure/ Heart Disease? *YesNo

Are you taking any Medication on a regular basis? *YesNo

Do you Smoke or consume Alcohol? (Alcohol- 2-3 times in a week) *YesNo

Do you have a disturbed sleep cycle? *YesNo

Do you have high level of Stress? Are you losing your temper frequently or do you suffer from Anxiety or Depression? *YesNo

Do you Exercise regularly? ( 2-3 times or more in a week) *YesNo

Do you have outside meal two or more times a week? *YesNo

Do you have a family history of Allergy/ Asthma/ High BP/ DM/ Thyroid/ Heart Ailments/ Cancer/ TB? *YesNo

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