His Holiness Maharishi Mahesh Yogi

Significant improvements have been reported by more than 25.000 people through this non-invasive,
non-medical approach to alleviating pain and suffering

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HAZARDS OF MODERN MEDICINE

Application

Step 3 of 3: Application Form for a Consultation

Required fields are marked with stars: ***

Personal Information

*** First Name:
*** Last Name (Family Name):
*** Age:
*** Gender:: Male Female
*** E-mail:
or Fax:
or Postal Address with your name and country:
Phone:

Where do you want to receive your MVVT consultation?

Select your preferred location:

Please give details on the disorders for which you wish to have a consultation:

Required fields are marked with stars: ***

(not required when selecting Elimination of Pragyaparadh or
Enlivening the 40 aspects of Veda in physiology)

First Disorder

*** Please select your first disorder or choose it from the structured list:

*** Brief description of this disorder:
*** Part of body which is most affected by this disorder:
Pain, if any:: Sharp Dull Burning Itching
Has your disorder been medically diagnosed?: Yes No
If "Yes", Date of Diagnosis:: Day: Month: Year:
Disorder has been present for (enter number):: Years Months Weeks
Frequency of occurrence:
*** Severity of disorder:
*** Degree of disability:
Your present medication:: (this information will be used only for evaluating the programme)
Further Comments:

Second Disorder (if applicable)

Please select your second disorder or choose it from the structured list:

*** Brief description of this disorder:
*** Part of body which is most affected by this disorder:
Pain, if any:: Sharp Dull Burning Itching
Has your disorder been medically diagnosed?: Yes No
If "Yes", Date of Diagnosis:: Day: Month: Year:
Disorder has been present for (enter number):: Years Months Weeks
Frequency of occurrence:
*** Severity of disorder:
*** Degree of disability:
Your present medication:: (this information will be used only for evaluating the programme)
Further Comments:

Third Disorder (if applicable)

Please select your third disorder or choose it from the structured list:

*** Brief description of this disorder:
*** Part of body which is most affected by this disorder:
Pain, if any:: Sharp Dull Burning Itching
Has your disorder been medically diagnosed?: Yes No
If "Yes", Date of Diagnosis:: Day: Month: Year:
Disorder has been present for (enter number):: Years Months Weeks
Frequency of occurrence:
*** Severity of disorder:
*** Degree of disability:
Your present medication:: (this information will be used only for evaluating the programme)
Further Comments:

(If you wish to apply for more disorders, please fill out more applications like this.
Make sure that you give the same name as in this application.)