Personal Details
Let's start with your basic information.
Medical History
Please tick all ongoing diagnosed or undiagnosed health concerns that apply to you.
Autoimmune Disorders (Degenerative)
Autoimmune Disorders (Lifestyle & Chronic)
Chronic Pain Disorders (Acute & Chronic)
📁 Upload Medical Records (Optional but Helpful)
Share any relevant documents — previous prescriptions, specialist reports, discharge summaries, or investigation reports that may help us understand your history better.
Symptoms & Lifestyle
Please share details about your current symptoms and daily lifestyle habits to help us better understand your overall health condition.
Current Medications & Supplements
Please list everything you are currently taking — including medications, Ayurvedic preparations, homeopathy, supplements, and home remedies.
📌 Please include the name and dose for each item. This is essential for safe protocol design.
Include DMARDs, immunosuppressants, steroids, biologics, vitamins, and any traditional or alternative medicines.
Blood Work & Lab Reports
Upload your recent reports and / or fill in the key values below
⚠️
Blood work is mandatory for consultation.
We need your recent lab reports in order to assess your condition and design an appropriate treatment protocol.
If you do not have any recent blood reports, please get in touch with us before booking — we can guide you on exactly which tests to get done.
Book your autoimmunity care 101 parameters package
📞 Contact us: +91 96191 47111
📎 Upload Recent / Latest Lab Reports
Please attach your most recent reports below. Multiple files can be uploaded across the slots provided.
📋 Fill Latest Values (Whichever Applicable)
Enter values from your most recent blood test. Leave blank if not available.
