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

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

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: : </td> </tr> <tr class="tablebg01"> <td>15</td> <td>Any other problem, which you would like to describe :</td> <td><strong>:</strong></td> <td><textarea name="any_other_prob" id="any_other_prob" onkeypress="javascript:return check(event);" rows="3" > 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

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: :
Word Verification *		: