Consultation

For consultation you can contact our competent team of Hakims and Vaids who implement and monitor the quality of our products. Doctors, Hakims and Vaids prescribe the Herbal Supplements with full confidence as they come from Dehlvi Naturals.

Enquiry Form

• General
• Male
• Female

General

( * fields are mandatory)

Email Address *	:
Name of Patient *	:
Age (Yrs.) *	:
Weight (Kg)	:
Height	:	select feet 1 ft 2 ft 3 ft 4 ft 5 ft 6 ft select inch 1 inch 2 inch 3 inch 4 inch 5 inch 6 inch 7 inch 8 inch 9 inch 10 inch 11 inch
Profession	:
Marital Status *	:	Married   Unmarried

If married, mention the date of marriage	:
No. of Children	:

Complete Postal Address		:
City *		:
State *		:
PIN / Zip Code		:
Country *		:
Phone No. with STD code (Optional)		:
Do you suffer from Hypertension ? *		:	Yes   No
If yes, mention your BP		:	Systolic Diatolic
Are you suffering from Diabetes ? *		:	Yes   No
If yes, mention Blood Sugar Level		:	Fasting PP Random
1	Main problems *	:
2	For how long, are you suffering from these complaints ?	:
3	Appetite	:	Good  Average   Poor
4	Motion	:	Normal  Constipation  Loose
5	Food Habit	:	Vegetarian  Non-Veg
6	Built	:	Fat  Moderate  Thin
7	Do you have the problem of burning chest ?	:	Often  Sometimes Never
8	Do you suffer from headache ?	:	Often   Sometimes  Never
9	Do you suffer from sleeplessness ?	:	Often   Sometimes  Never
10	Do you smoke or chew tobacco ?	:	Yes   No
11	Do you drink excessive tea or coffee ?	:	Yes  No
12	Do you consume alcohol ?	:	Yes   No
13	If you have suffered from any major disease earlier, kindly do mention it here ?	:
14	If there is a history of any hereditary disease in your family, kindly do mention it here ?	:
15	If you have undergone any medical investigations, kindly mention here	:
16	Any other problem, which you would like to describe	:
17	Word Verification *

Male

( * fields are mandatory)

Email Address *	:
Name of Patient *	:
Age (Yrs.) *	:
Weight (Kg)	:
Height	:	select feet 1 ft 2 ft 3 ft 4 ft 5 ft 6 ft select inch 1 inch 2 inch 3 inch 4 inch 5 inch 6 inch 7 inch 8 inch 9 inch 10 inch 11 inch
Profession	:
Marital Status *	:	Married   Unmarried

If married, mention the date of marriage	:
No. of Children	:

Complete Postal Address		:
City *		:
State *		:
PIN / Zip Code		:
Country *		:
Phone No. with STD code (Optional)		:
Do you suffer from Hypertension ? *		:	Yes  No
If yes, mention your BP		:	Systolic Diatolic
Are you suffering from Diabetes ? *		:	Yes   No
If yes, mention Blood Sugar Level		:	Fasting PP Random
1	Main problems *	:
2	Appetite	:	Good  Average  Poor
3	Motion	:	Normal  Constipation  Loose
4	Food Habit	:	Vegetarian   Non-Veg
5	Built	:	Fat  Moderate   Thin
6	Do you smoke or chew tobacco ?	:	Yes, Regularly  Sometimes   Never
7	Do you feel burning sensation while passing urine ?	:	Often  Sometimes  Never
8	Are you suffering from involuntary flow of sticky fluid in urine ?	:	Often   Sometimes   Never
9	Are you suffering from nocturnal emissions ?	:	Often   Sometimes   Never
10	If yes, then how many times a month ?	:
11	Are you suffering or have ever suffered from any Sexually Transmitted Infection (e.g., Gonorrhoea, Syphilis, HIV, etc.) ?	:	Yes No
12	Are you suffering from any of these problems:	:
	(a) Erectile Dysfunction	:	Always   Sometimes Never
	(b) Lack of Stiffness	:	Always   Sometimes Never
	(c) Premature Ejaculation	:	Always   Sometimes Never
	(d) Lack of Desire for Sex	:	Always   Sometimes Never
13	If there is any deformity in the male organ, please clarify	:
14	If you have undergone any medical investigations, kindly mention here:	:
15	Any other problem, which you would like to describe :	:
16	Word Verification *

Female

( * fields are mandatory)

Email Address *	:
Name of Patient *	:
Age (Yrs.) *	:
Weight (Kg)	:
Height	:	select feet 1 ft 2 ft 3 ft 4 ft 5 ft 6 ft select inch 1 inch 2 inch 3 inch 4 inch 5 inch 6 inch 7 inch 8 inch 9 inch 10 inch 11 inch
Profession	:
Marital Status *	:	Married   Unmarried

If married, mention the date of marriage	:
No. of Children	:

Complete Postal Address		:
City *		:
State *		:
PIN / Zip Code		:
Country *		:
Phone No. with STD code (Optional)		:
Do you suffer from Hypertension ? *		:	Yes   No
If yes, mention your BP		:	Systolic Diatolic
Are you suffering from Diabetes ? *		:	Yes   No
If yes, mention Blood Sugar Level		:	Fasting PP Random
1	Main problems *	:
2	Appetite	:	Good  Average   Poor
3	Motion	:	Normal   Constipation Loose
4	Food Habit	:	Vegetarian Non-Veg
5	Built	:	Fat Moderate Thin
6	Do you have the problem of burning chest ?	:	Often   Sometimes   Never
7	Do you suffer from headache ?	:	Often  Sometimes   Never
8	Do you suffer from sleeplessness ?	:	Often   Sometimes   Never
9	Do you suffer from any irritation or burning sensation when passing urine ?	:	Often  Sometimes   Never
10	Do you have the problem of white discharge / leucorrhoea ?	:	Often   Sometimes   Never
11	Do you have pain in abdomen ?	:	Often   Sometimes   Never
12	Do you have pain in the back ?	:	Often  Sometimes   Never
13	Do you have pain the legs ?	:	Often  Sometimes   Never
14	Do you have cramps in calf muscles ?	:	Often   Sometimes  Never
15	Do you have the problem of burning in soles ?	:	Often   Sometimes   Never
16	Is there any feeling of nausea or vomiting ?	:	Often    Sometimes   Never
17	Are the menstrual periods regular ?	:	Yes   No
18	Are the menstrual periods painful ?	:	Yes   No
19	Are you presently pregnant ?	:	Yes   No
20	Mention the date of last menses	:
21	Have you ever suffered from any miscarriage ?	:	Yes  No
22	If yes, how many times ?	:
23	Was there any child birth after miscarriage ?	:	Yes   No
24	If you have undergone any medical investigations, kindly mention here	:
25	Any other problem, which you would like to describe:	:
17	Word Verification *