Intake Form Your Email* Your Full Name* FemaleMalePrefer not to say Date of Birth* Phone Number(Primary) * Phone Number(Secondary) Intake Form - Purpose of Visit Description How do you know about Ojas Ayurveda Online search (Google/Yelp/Facebook/Bing etc...)Ojas Ayurveda WebsiteLotus Pond (website or facility)Natural Awakenings magazineOther Magazines (Welness / WoW / etc..) Medical History Anaemia SelfFamily Alcohol Abuse SelfFamily Arthritis SelfFamily Asthma SelfFamily Cancer SelfFamily Chicken Pox SelfFamily Colitis SelfFamily Chronic Pain SelfFamily Depression SelfFamily Diabetes SelfFamily Dizziness SelfFamily Emphysema SelfFamily Fatigue SelfFamily Gall Bladder Disorders SelfFamily Gout SelfFamily Heart Attack SelfFamily Hepatitis SelfFamily High Blood Pressure SelfFamily Kidney Diseases SelfFamily Kidney Infection SelfFamily Low Blood Pressure SelfFamily Lung Infection SelfFamily Measles SelfFamily Migraine Headaches SelfFamily Mumps SelfFamily Nervous Breakdown SelfFamily Pregnancy SelfFamily Rheumatic Fever SelfFamily Sickle Cell Anemia SelfFamily Sleep Disorders SelfFamily Sinusitis SelfFamily STD SelfFamily Stomach Ulcer SelfFamily Stroke SelfFamily Thyroid Disease SelfFamily Other SelfFamily
