*** Last Name (Family Name):

 Male          Female

*** E-mail:

(Birth Date Details, optional:)

Date of Birth:

Day:    Month: Jan. Feb. Mar. Apr. May June July Aug. Sep. Oct. Nov. Dec.     Year:

Time of Birth:

Hour: 00 am 01 am 02 am 03 am 04 am 05 am 06 am 07 am 08 am 09 am 10 am 11 am 12 am 01 pm 02 pm 03 pm 04 pm 05 pm 06 pm 07 pm 08 pm 09 pm 10 pm 11 pm    Minute:    Second:

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First Disorder

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

Let me choose from a structured list

  *** Please highlight from the list *** My disorder is not on the list Elimination of Pragyaparadh Enlivening the 40 aspects of Veda in physiology Osteoarthritis of the knees Osteoarthritis of the spine Osteoarthritis of the low back and/or hips Osteoarthritis of the neck and /or shoulder Osteoarthritis of the wrists, thumbs and/or fingers Osteoarthritis of the ankles, heels and/or feet Osteoarthritis of the elbows Osteoarthritis of another area Rheumatoid Arthritis of the wrists, small joints of the hands, thumbs and/or fingers Rheumatoid Arthritis of the knees Rheumatoid Arthritis of the ankles, heels and/or small joints of the foot Rheumatoid Arthritis of the shoulders and/or neck Rheumatoid Arthritisof the hips Rheumatoid Arthritis of the elbows Rheumatoid Arthritis of the jaw Rheumatoid Arthritis of another area Spondylitis of the neck Frozen shoulder Back pain--neck and/or shoulders Back pain--upper back Back pain--mid back Back pain--lower back & hip Disk-related problems of the neck and/or upper back Disk-related problems of the mid back Disk-related problems of the lower back Stress Fracture of the upper extremities Stress Fracture of the lower extremities Stress Fracture of another area Sciatica Heel spurs Tension headache Migraine headache Other headache Pain syndrome of the head area Pain syndrome of the upper back Pain syndrome of the mid back Pain syndrome of the lower back Pain syndrome of the upper extremities Pain syndrome of the lower extremities Pain syndrome of the chest area Pain syndrome of the abdominal area Pain syndrome of the another area Neuralgia (nerve pain) or pinched nerve in the head Neuralgia (nerve pain) or pinched nerve in the neck Neuralgia (nerve pain) or pinched nerve in the upper back Neuralgia (nerve pain) or pinched nerve in the mid back Neuralgia (nerve pain) or pinched nerve in the lower back Neuralgia (nerve pain) or pinched nerve of the upper extremities Neuralgia (nerve pain) or pinched nerve of the lower extremities Neuralgia (nerve pain) or pinched nerve of another area Carpal tunnel syndrome Pain following herpes zoster in the head area Pain following herpes zoster in the chest area Pain following herpes zoster in the back area Pain following herpes zoster in the abdominal area Pain following herpes zoster in the upper extremities Pain following herpes zoster in the lower extremities Pain following herpes zoster in another area Pain from cancer in the head Pain from cancer in the chest area Pain from cancer in the back area Pain from cancer in the abdominal area Pain from cancer in the upper extremities Pain from cancer in the lower extremities Pain from cancer in another area Digestive problems with nausea Digestive problems with diarrhea Digestive problems with constipation Digestive problems with abdominal ache or pain Digestive problems with belching Digestive problems with bloating Digestive problems with weak digestion Digestive problems with slow digestion Digestive problems with excess acid Digestive problems with general weakness Digestive problems--Any other digestive problems Anorexia Gastritis with hyperacidity Gastritis/ achlorhydric (without acid) Irritable bowel syndrome Irritable bowel syndrome with constipation Irritable bowel syndrome with diarrhea Irritable bowel syndrome with abdominal pain Colitis Constipation Dysentery: Infectious Dysentery: Inflammatory Hyperacidity Gastric ulcer Duodenal ulcer Heartburn Liver enlargement Hepatitis (Except Type B) Anemia (due to poor digestion) Hemorrhoids: non-bleeding Hemorrhoids: bleeding Anal fissure Asthma Asthma related to allergy Bronchitis Bronchitis--with dry cough Bronchitis (chronic cough with sputum production) Bronchitis related to allergy Sinusitis Sinusitis related to infection Sinusitis related to allergy Psoriasis of the face and/or scalp Psoriasis of the chest Psoriasis of the back area Psoriasis of the abdominal area Psoriasis of the upper extremities Psoriasis of the lower extremities Psoriasis of another area Eczema of the face Eczema of the scalp Eczema of the chest Eczema of the back area Eczema of the abdominal area Eczema of the upper extremities Eczema of the lower extremities Eczema of another area Atopic dermatitis of the face Atopic dermatitis of the scalp Atopic dermatitis of the chest Atopic dermatitis of the back area Atopic dermatitis of the abdominal area Atopic dermatitis of the upper extremities Atopic dermatitis of the lower extremities Atopic dermatitis of another area Burning and/or itching sensations of the face Burning and/or itching sensations of the scalp Burning and/or itching sensations of the chest Burning and/or itching sensation of the back area Burning and/or itching sensations of the abdominal area Burning and/or itching sensations of the upper extremities Burning and/or itching sensations of the lower extremities Burning and/or itching sensations of another area Stable angina, heart condition Ectopic heart beat (palpitations) Ectopic heart beat associated with anxiety Hypertension: Primary Hypertension: Secondary (due to a systemic illness) Hypertension: related to the kidneys Hypertension: related to adrenal glands Peripheral vascular disease: poor circulation Peripheral vascular disease: poor circulation (cold extremities) Peripheral vascular disease: varicose veins Insomnia--disturbed sleep Insomnia--disturbed sleep due to anxiety Insomnia--disturbed sleep due to excitation Insomnia--long term Anxiety Anxiety associated with sleep disturbance Anxiety associated with substance abuse Depression Depression associated with sleep disorder Forgetfulness Anger Emotional Instability Grief Phobia Chronic itching and/or redness of the eyes Chronic pain of the eyes Pressure around the eyes Fatigue of the eyes Menstrual disorders: dysmenorrhea (excessive pain with menstruation) Menstrual disorders: abnormal menstruation associated with menopause Menstrual disorders: associated with migraine Menstrual disorders: excessive menstrual flow Premenstrual syndrome resulting in headache Premenstrual syndrome resulting in emotional imbalance Premenstrual syndrome resulting in digestive difficulties Vaginal discharge (leukorrhea) Menopausal difficulties: hot flashes Menopausal difficulties: abnormal menstruation Menopausal difficulties: dryness Menopausal difficulties: emotional imbalance General weakness Chronic fatigue syndrome Vertigo (dizziness) Numbness affecting the upper extremities Numbness affecting the lower extremities Numbness affecting another area Paralysis involving the face Paralysis involving speech Paralysis involving the neck and shoulders Paralysis involving the upper extremities Paralysis involving the lower extremities Uterine fibroids (benign uterine tumors) Diabetes Thyroid problems--overactive (hyperthyroidism) Thyroid problems--underactive (hypothyroidism) Adrenal gland problems Adrenal gland problems: associated with hypertension Kidney disorder caused by infection Kidney disorder caused by inflammation (nephritis and nephrosis) Kidney disorder caused by obstruction Kidney disorder caused by diabetes or other systemic disorders Allergy: itching eyes Allergy: tearing eyes Allergy: congestion in the nose and sinuses Allergy: congestion in the lungs Allergy: itching skin Inflammation of the glands Ringing of the ears (tinnitis) Prostatitis Parkinson's disease with tremor Parkinson's disease with stiffness Parkinson's disease with a gait disorder Benign tumor located in the abdominal area Benign tumor located in the upper extremities Benign tumor located in the lower extremities Dental pain caused by infection in the teeth Dental pain caused by infection in the gums Wound to the face Wound to the head Wound to the chest Wound to the abdominal area Wound to the upper extremities Wound to the lower extremities Eye problems due to systemic weakness Visual weakness Visual weakness--due to old age Visual weakness--cataracts Chronic external ear infection (with discharge and itching) Hearing problems Tonsilitis Kidney stones

Sharp        Dull        Burning        Itching 

Yes   No

If "Yes", Date of Diagnosis: 
Day: , Month: , Year:

Years, Months, Weeks.

Daily,   Weekly,   Monthly,   Continuously  

 Severe   Moderate   Mild

 Disabling,           Moderately disabling,
Mildly disabling, Not disabling.

(this information will be used only for evaluating the programme):

Second Disorder if applicable

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

Let me choose from a structured list

*** Please highlight from the list if applicable *** My disorder is not on the list Elimination of Pragyaparadh Enlivening the 40 aspects of Veda in physiology Osteoarthritis of the knees Osteoarthritis of the knees Osteoarthritis of the spine Osteoarthritis of the low back and/or hips Osteoarthritis of the neck and /or shoulder Osteoarthritis of the wrists, thumbs and/or fingers Osteoarthritis of the ankles, heels and/or feet Osteoarthritis of the elbows Osteoarthritis of another area Rheumatoid Arthritis of the wrists, small joints of the hands, thumbs and/or fingers Rheumatoid Arthritis of the knees Rheumatoid Arthritis of the ankles, heels and/or small joints of the foot Rheumatoid Arthritis of the shoulders and/or neck Rheumatoid Arthritisof the hips Rheumatoid Arthritis of the elbows Rheumatoid Arthritis of the jaw Rheumatoid Arthritis of another area Spondylitis of the neck Frozen shoulder Back pain--neck and/or shoulders Back pain--upper back Back pain--mid back Back pain--lower back & hip Disk-related problems of the neck and/or upper back Disk-related problems of the mid back Disk-related problems of the lower back Stress Fracture of the upper extremities Stress Fracture of the lower extremities Stress Fracture of another area Sciatica Heel spurs Tension headache Migraine headache Other headache Pain syndrome of the head area Pain syndrome of the upper back Pain syndrome of the mid back Pain syndrome of the lower back Pain syndrome of the upper extremities Pain syndrome of the lower extremities Pain syndrome of the chest area Pain syndrome of the abdominal area Pain syndrome of the another area Neuralgia (nerve pain) or pinched nerve in the head Neuralgia (nerve pain) or pinched nerve in the neck Neuralgia (nerve pain) or pinched nerve in the upper back Neuralgia (nerve pain) or pinched nerve in the mid back Neuralgia (nerve pain) or pinched nerve in the lower back Neuralgia (nerve pain) or pinched nerve of the upper extremities Neuralgia (nerve pain) or pinched nerve of the lower extremities Neuralgia (nerve pain) or pinched nerve of another area Carpal tunnel syndrome Pain following herpes zoster in the head area Pain following herpes zoster in the chest area Pain following herpes zoster in the back area Pain following herpes zoster in the abdominal area Pain following herpes zoster in the upper extremities Pain following herpes zoster in the lower extremities Pain following herpes zoster in another area Pain from cancer in the head Pain from cancer in the chest area Pain from cancer in the back area Pain from cancer in the abdominal area Pain from cancer in the upper extremities Pain from cancer in the lower extremities Pain from cancer in another area Digestive problems with nausea Digestive problems with diarrhea Digestive problems with constipation Digestive problems with abdominal ache or pain Digestive problems with belching Digestive problems with bloating Digestive problems with weak digestion Digestive problems with slow digestion Digestive problems with excess acid Digestive problems with general weakness Digestive problems--Any other digestive problems Anorexia Gastritis with hyperacidity Gastritis/ achlorhydric (without acid) Irritable bowel syndrome Irritable bowel syndrome with constipation Irritable bowel syndrome with diarrhea Irritable bowel syndrome with abdominal pain Colitis Constipation Dysentery: Infectious Dysentery: Inflammatory Hyperacidity Gastric ulcer Duodenal ulcer Heartburn Liver enlargement Hepatitis (Except Type B) Anemia (due to poor digestion) Hemorrhoids: non-bleeding Hemorrhoids: bleeding Anal fissure Asthma Asthma related to allergy Bronchitis Bronchitis--with dry cough Bronchitis (chronic cough with sputum production) Bronchitis related to allergy Sinusitis Sinusitis related to infection Sinusitis related to allergy Psoriasis of the face and/or scalp Psoriasis of the chest Psoriasis of the back area Psoriasis of the abdominal area Psoriasis of the upper extremities Psoriasis of the lower extremities Psoriasis of another area Eczema of the face Eczema of the scalp Eczema of the chest Eczema of the back area Eczema of the abdominal area Eczema of the upper extremities Eczema of the lower extremities Eczema of another area Atopic dermatitis of the face Atopic dermatitis of the scalp Atopic dermatitis of the chest Atopic dermatitis of the back area Atopic dermatitis of the abdominal area Atopic dermatitis of the upper extremities Atopic dermatitis of the lower extremities Atopic dermatitis of another area Burning and/or itching sensations of the face Burning and/or itching sensations of the scalp Burning and/or itching sensations of the chest Burning and/or itching sensation of the back area Burning and/or itching sensations of the abdominal area Burning and/or itching sensations of the upper extremities Burning and/or itching sensations of the lower extremities Burning and/or itching sensations of another area Stable angina, heart condition Ectopic heart beat (palpitations) Ectopic heart beat associated with anxiety Hypertension: Primary Hypertension: Secondary (due to a systemic illness) Hypertension: related to the kidneys Hypertension: related to adrenal glands Peripheral vascular disease: poor circulation Peripheral vascular disease: poor circulation (cold extremities) Peripheral vascular disease: varicose veins Insomnia--disturbed sleep Insomnia--disturbed sleep due to anxiety Insomnia--disturbed sleep due to excitation Insomnia--long term Anxiety Anxiety associated with sleep disturbance Anxiety associated with substance abuse Depression Depression associated with sleep disorder Forgetfulness Anger Emotional Instability Grief Phobia Chronic itching and/or redness of the eyes Chronic pain of the eyes Pressure around the eyes Fatigue of the eyes Menstrual disorders: dysmenorrhea (excessive pain with menstruation) Menstrual disorders: abnormal menstruation associated with menopause Menstrual disorders: associated with migraine Menstrual disorders: excessive menstrual flow Premenstrual syndrome resulting in headache Premenstrual syndrome resulting in emotional imbalance Premenstrual syndrome resulting in digestive difficulties Vaginal discharge (leukorrhea) Menopausal difficulties: hot flashes Menopausal difficulties: abnormal menstruation Menopausal difficulties: dryness Menopausal difficulties: emotional imbalance General weakness Chronic fatigue syndrome Vertigo (dizziness) Numbness affecting the upper extremities Numbness affecting the lower extremities Numbness affecting another area Paralysis involving the face Paralysis involving speech Paralysis involving the neck and shoulders Paralysis involving the upper extremities Paralysis involving the lower extremities Uterine fibroids (benign uterine tumors) Diabetes Thyroid problems--overactive (hyperthyroidism) Thyroid problems--underactive (hypothyroidism) Adrenal gland problems Adrenal gland problems: associated with hypertension Kidney disorder caused by infection Kidney disorder caused by inflammation (nephritis and nephrosis) Kidney disorder caused by obstruction Kidney disorder caused by diabetes or other systemic disorders Allergy: itching eyes Allergy: tearing eyes Allergy: congestion in the nose and sinuses Allergy: congestion in the lungs Allergy: itching skin Inflammation of the glands Ringing of the ears (tinnitis) Prostatitis Parkinson's disease with tremor Parkinson's disease with stiffness Parkinson's disease with a gait disorder Benign tumor located in the abdominal area Benign tumor located in the upper extremities Benign tumor located in the lower extremities Dental pain caused by infection in the teeth Dental pain caused by infection in the gums Wound to the face Wound to the head Wound to the chest Wound to the abdominal area Wound to the upper extremities Wound to the lower extremities Eye problems due to systemic weakness Visual weakness Visual weakness--due to old age Visual weakness--cataracts Chronic external ear infection (with discharge and itching) Hearing problems Tonsilitis Kidney stones *** No, I only apply for one 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 (check one):

Daily,   Weekly,   Monthly,   Continuously  

*** Severity of disorder (check one):

Severe   Moderate   Mild

*** Degree of disability (check one):

Disabling,          Moderately disabling,
Mildly disabling, Not disabling.

Your present medication

(this information will be used only for evaluating the programme):

Further Comments:

Third Disorder if applicable

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

Let me choose from a 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 (check one):

Daily,   Weekly,   Monthly,   Continuously  

*** Severity of disorder (check one):

Severe   Moderate   Mild

*** Degree of disability (check one):

Disabling,          Moderately disabling,
Mildly disabling, Not disabling.

Your present medication 

(this information will be used only for evaluating the programme):