Online Consultation

Personal information

Medical Information

Past Treatment Information

Trilok Ayurveda Name : : ".$name." DOB : : ".$dob." Height : : ".$height." Email : : ".$email." Weight : : ".$weight." Marital_status : : ".$marital_status." Occupation : : ".$occupation." Contact No. : : ".$contact." Chief Compalaint with Duration : : ".$chief_complaint." Mode of Onset : : ".$mode_onset." Past History : : ".$past_history." Family History : : ".$family_history." Number of Pregnancy : : ".$num_pregnancy." Number of Alive Kids : : ".$num_alivekids." Mode of Delivery : : ".$mo_delevery." Number of Pregnancy Surgery : : ".$num_preg_surg." Menstrual History : : ".$menstrual_history." Name of Doctor : : ".$name_doctor." Name of Hospital : : ".$name_hospital." Place : : ".$place." Date : : ".$date." Past Treatment : : ".$past_treat." Current Treatment : : ".$curr_treat." Life Style of Patient : : ".$life_style." Body Built : : ".$body_built." Complexion : : ".$complexion." Skin Nature : : ".$skin_nature." Hair Nature : : ".$hair_nature." Joint Characterstic : : ".$joint_char." Appearance of Veins and Tendons : : ".$veins_tendons." Patient's Body is' : : ".$patient_body." Tempreture Preference : : ".$tem_pref." Eye : : ".$eye." Nature of Teeth and Gums : : ".$teeth_gums." Appetite : : ".$appetite." Preference of Taste : : ".$pref_taste." Sweating : : ".$sweating." Excretory Habits : : ".$exc_habits." Urination : : ".$urination." Sleep : : ".$sleep." Psycological Status : : ".$psyco_status." Memory : : ".$memory." Thanks ".$name." for Contacting us we will revert to you back ASAP!!! "; $message= " ".stripslashes($email_body)." "; $headers = "From:query@brainrock.in \r\n"; $headers = 'MIME-Version: 1.0' . "\r\n"; $headers .= 'Content-type: text/html; charset=iso-8859-1' . "\r\n"; $send=mail ($to,$subject,$message,$headers); if($send == TRUE) { echo""; echo""; } } ?>