Pre-consultation form Step 1 of 2 50% Our fee Live Chat Consultation - Rs 200 for a 30-minute session Phone Consultation - Rs 250 for a 30-minute session Note : After Filling the below form, you can schedule the timing and book consultation. Please contact our support desk for any difficulty with booking or submission of form. Live Chat On Our Website Click to chat with support Whatsapp : +917012232608 Email - [email protected]Type*New UserFollow UpI already Filled this Case FormFirst Time or FollowupReportsDo you Have Medical Reports or Past Prescriptions ?* Yes No Important Notes:* I agree to thisCannarelief is for chronic conditions and may not be prescribed for mild pain or as the first line of treatment or other less severe conditions. If there are no diagnoses or past treatments or past prescription reports, The doctor may not prescribe this medicine directly. In such cases, the doctor may prescribe other Ayurvedic medicines as the first line of treatment. Medical Reports or Past Prescriptions Drop files here or Select files Accepted file types: jpg, jpeg, png, pdf, Max. file size: 10 MB, Max. files: 8. Upload Medical Reports or Past Prescriptions **Max Upload Limit is 10 MB ID Proof* Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, Max. file size: 10 MB, Max. files: 3. Any of the Valid ID ProofPatient IDPatient ID* Enter Your Patient ID (Please check the last time mail or prescription)Email Address* HiddenProfile DetailsName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Name Last Name Name of the PatientGender*MaleFemaleTransgenderEmail Address* Phone No*Date of Birth* DD slash MM slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Health ComplaintMain Complaint*Tell us about your health problemPast Treatment History*History of Medications* HiddenMarital Status Single Married Divorced Widowed Seperated Occupation* Weight in KG*Please enter a number from 10 to 200.Height in CM*Please enter a number from 10 to 220.Diet* Pure Veg Non Veg Mixed HiddenHabit of Vega Dharana Always Suppresses Urges Frequently Occasionally Recreational habits* Alcohol Smoking Tobacco Other Family Members Having No such Habbits Bowel* Normal Hard Stools Straining Passing stools less than 3 times/week Appetite* Poor Moderate Good Very Good Micturition* Normal 3 or Less than 3 times per day 5 or Less than 5 times per day More than 5 Times Urination at night Yellowish Sleep* Good Sleep Disturbed Less than 6 hrs daily History of Diabetes* Yes No History of Hypertension* Yes No History of Cardiovascular Disease* Yes No Do you have past experience of using Cannabis Products?* Yes No Allgergy (If yes, Please mention)* Any Drug or Food Allergy?Antidepressants*Are you taking any antidepressants/sleep medication? If yes, please specifyMenstrual History* Regular Cycle Irregular Cycle 2-5 Days 6-7 Days Very Painful Itching White Discharge Consent* I agree to the followingI hereby agree that the above submitted informations are correct to the best of my knowledge and I understand the importance of the data provided here for the analysis and diagnosis of the condition. I completely own the responsibilities of recieving the telemedicine advises by providing the wrong information. Issual of prescription is not guaranteed with the consultation at CareAyu. The Doctor holds the "Right" to prescribe the medicine or not. There will not be any refunds due to these decisions. I understand that telemedicine is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to Careayu providing healthcare services to me via Telephone, Email or Chat. The conversations will be recorded for future references and it will be maintained strictly under the privacy protections of the user. This form is Integrated with Hemplife and they do have limited access to this form data and both parties are hereby agreed to protect the privacy of the user.