Free online consultation<title> <meta name ="keywords" content ="kerala ayurveda, ayurveda treatments, panchakarma, rejuvenation, detoxification, purification, kerala treatments, chronic diseases, arthritis, back pain, sciatica, relaxation treatments"> <meta name="description" content= "free online consultation for kerala ayurveda treatments for total health care"> <META NAME="Author" CONTENT="Srikant Nair"> </HEAD> <meta name="robots" content="INDEX, FOLLOW"> <meta name="author" content="Srikant Nair"> <META HTTP-EQUIV="Reply-to" CONTENT="ayuryog.kerala@gmail.com"> <META NAME="Creation Date" CONTENT="05/052009"> <META NAME="revisit-after" CONTENT="15 days"> <meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1"> <style type="text/css"> td img {display: block;}body { background-color: #002E5B; margin-left: 0px; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; } .style4 {font-family: Arial; font-size: 12px; font-weight: bold; color: #091177; } a:link { color: #0C227C; text-decoration: none; } a:visited { text-decoration: none; color: #FFFFFF; } a:hover { text-decoration: underline; color: #1A4DD2; } a:active { text-decoration: none; color: #0C227C; } .style8 { font-family: Verdana; font-size: 12px; } .style60 {font-size: 16px; font-weight: bold; color: #003399; font-family: Arial; } .style80 {font-size: 10px} .style110 {color: #990000; text-align: justify; line-height: 20px; font-family: Verdana; font-size: 13px;} </style> <script language="JavaScript">  function validateForm() { if(document.form1.Name.value=="") { alert("Please mention your name"); document.form1.Name.focus(); return false; } if(document.form1.City.value=="") { alert("Please enter your City"); document.form1.City.focus(); return false; } if(document.form1.Postal_Code.value=="") { alert("Please enter Postal Code"); document.form1.Postal_Code.focus(); return false; } if(document.form1.Telephone.value=="") { alert("Please enter Telephone no"); document.form1.Telephone.focus(); return false; } mytmpvar=document.form1.email; if(document.form1.email.value=="") { alert("Please enter your email address"); document.form1.email.focus(); return false; } mystr1=/@/i; if ((mytmpvar.value.length<=0) || (mytmpvar.value.search(mystr1) <=0 ) ) { alert("The E-mail address you have entered is not appropriate."); mytmpvar.focus(); return false; } if(mytmpvar.value.indexOf('@',1) ==-1) { alert("The E-mail address you have entered must have @ sign.") mytmpvar.focus(); return false; } if(mytmpvar.value.indexOf('.',3) ==-1) { alert("The E-mail address you have entered must have . sign.") mytmpvar.focus(); return false; } l2=document.form1.email.value.length; for(i=0;i<l2;i++) { c2=document.form1.email.value.charAt(i); if(c2==" ") { alert("No space allow in email"); document.form1.email.focus(); return false; } }/* end for */ if(document.form1.age.value=="") { alert("Please enter your Age"); document.form1.age.focus(); return false; } if(document.form1.sex.value=="") { alert("Please enter your Sex"); document.form1.sex.focus(); return false; } } </script> <script language="JavaScript" src="mm_menu.js"></script> <link href="text.css" rel="stylesheet" type="text/css"> <link href="headline.css" rel="stylesheet" type="text/css"> <style type="text/css">  </style> </head> <body onLoad="MM_CheckFlashVersion('8,0,0,0','Content on this page requires a newer version of Macromedia Flash Player. Do you want to download it now?');"> <script language="JavaScript1.2">mmLoadMenus();</script> <table width="800" border="0" align="center" cellpadding="0" cellspacing="0"> <tr> <td><img src="images/spacer.gif" width="194" height="1" border="0" alt="" /></td> <td><img src="images/spacer.gif" width="606" height="1" border="0" alt="" /></td> <td><img src="images/spacer.gif" width="1" height="1" border="0" alt="" /></td> </tr> <tr> <td colspan="2" rowspan="3"><object classid="clsid:D27CDB6E-AE6D-11cf-96B8-444553540000" codebase="http://download.macromedia.com/pub/shockwave/cabs/flash/swflash.cab#version=7,0,19,0" width="800" height="180"> <param name="movie" value="FLASH/banerheader.swf" /> <param name="quality" value="high" /> <param name="wmode" value="transparent" /> <embed src="FLASH/banerheader.swf" width="800" height="180" quality="high" pluginspage="http://www.macromedia.com/go/getflashplayer" type="application/x-shockwave-flash" wmode="transparent"></embed> </object></td> <td><img src="images/spacer.gif" width="1" height="76" border="0" alt="" /></td> </tr> <tr> <td><img src="images/spacer.gif" width="1" height="56" border="0" alt="" /></td> </tr> <tr> <td><img src="images/spacer.gif" width="1" height="48" border="0" alt="" /></td> </tr> <tr> <td colspan="2"><object classid="clsid:D27CDB6E-AE6D-11cf-96B8-444553540000" codebase="http://download.macromedia.com/pub/shockwave/cabs/flash/swflash.cab#version=7,0,19,0" width="800" height="171"> <param name="movie" value="treatments2.swf"> <param name="quality" value="high"> <embed src="treatments2.swf" quality="high" pluginspage="http://www.macromedia.com/go/getflashplayer" type="application/x-shockwave-flash" width="800" height="171"></embed> </object></td> <td><img src="images/spacer.gif" width="1" height="171" border="0" alt="" /></td> </tr> <tr> <td colspan="2" background="images/index_r5_c1.jpg"><table width="800" border="0"> <tr> <td width="100"><div align="center" class="style4"><a href="index.html" name="link9" id="link1" onMouseOver="MM_showMenu(window.mm_menu_0803125054_0,-30,22,null,'link9')" onMouseOut="MM_startTimeout();"> <font color="#003366" size="2">Home</font></a></div></td> <td width="100"><div align="center" class="style4"><a href="kerelaspecial.html" name="link3" id="link2" onMouseOver="MM_showMenu(window.mm_menu_0803125301_0,-27,22,null,'link3')" onMouseOut="MM_startTimeout();"> <font color="#003366" size="2">Treatments</font></a></div></td> <td width="12%"><div align="center" class="style4"> <a href="photogallery.html"> <font size="2" color="#003366">Photo Gallery</font></a><font size="2"> </font> </div></td> <td width="100"><div align="center" class="style4"> <a href="consultation.html" name="link7" id="link5" onMouseOver="MM_showMenu(window.mm_menu_0803125947_0,-5,22,null,'link7')" onMouseOut="MM_startTimeout();"> <font size="2" color="#003366"><span align="center" class="activelink">Consultation</span></font></a><font size="2"> </font> </div></td> <td width="100"><div align="center" class="style4"><a href="ayurveda.html" name="link4" id="link6" onMouseOver="MM_showMenu(window.mm_menu_0803130106_0,-15,22,null,'link4')" onMouseOut="MM_startTimeout();"> <font color="#003366" size="2">Ayurveda</font></a></div></td> <td width="100"><div align="center" class="style4"><a href="weblink.html"> <font color="#003366" size="2">Web Links</font></a></div></td> <td width="100"><div align="center" class="style4"><a href="contact.html"> <font color="#003366" size="2">Contact</font></a></div></td> <td width="100"><div align="center" class="style4"><a href="sitemap.html"> <font color="#003366" size="2">Site Map </font></a></div> </div></td> </tr> </table></td> <td><img src="images/spacer.gif" width="1" height="28" border="0" alt="" /></td> </tr> <tr> <td colspan="2" rowspan="6" valign="top" bgcolor="#FFFFFF"><p><br /></p> <table width="100%" border="0"> <tr> <td width="7%"> </td> <td colspan="2" bgcolor="#DAEAFA" class="style60"><a href="#nasayam"></a> <p><strong>Online Consultation</strong> : </p></td> <td width="5%"> </td> </tr> <tr> <td> </td> <td colspan="2" class="style8"> </td> <td> </td> </tr> <tr> <td> </td> <td colspan="2" class="style8" vAlign="top"> <form onSubmit="return validateForm()" action="send_form.php" name="form1" method="post"> <table align="left" border="0" width="96%" NOWRAP="NOWRAP"> <tbody> <tr> <td width="174" align="left" class="style4"><font face="arial" size="2">Reference No :</font></td> <td width="488"><input maxLength="20" name="Ref" WIDTH="150" size="20"></td></tr> <tr> <td width="174" align="left" class="style111"><font size="2" face="arial" class="style4">Name :<font color="red">* (Mandatory)</font></font></td> <td width="488"><input name="Name" size="35" WIDTH="150"></td></tr> <tr> <td width="174" align="left" class="style4"><font face="arial" size="2">Organization :</font></td> <td width="488"><input name="Organization" size="35"></td></tr> <tr> <td width="174" align="left" class="style4"><font face="arial" size="2">Street Address :</font></td> <td width="488"><input name="Street_Address" size="35"></td></tr> <tr> <td width="174" align="left" class="style4"><font face="arial" size="2">City :<font color="red">* (Mandatory)</font></font></td> <td width="488"><input name="City" size="35"></td></tr> <tr> <td width="174" align="left" class="style4"><font face="arial" size="2">State :</font></td> <td width="488"><input name="State" size="35"></td></tr> <tr> <td width="174" align="left" class="style4"><font face="arial" size="2">Postal code :</font></td> <td width="488"><input name="Postal_Code" size="35"></td></tr> <tr> <td width="174" align="left" class="style4"><font face="arial" size="2">Country :<font color="red">* (Mandatory)</font></font></td> <td width="488"><input name="Country" size="35"></td></tr> <tr> <td width="174" align="left" class="style4"><font face="arial" size="2">Telephone :<font color="red">* (Mandatory)</font></font></td> <td width="488"><input name="Telephone" size="16"></td></tr> <tr> <td width="174" align="left" class="style4"><font face="arial" size="2">Fax :</font></td> <td width="488"><input name="Fax" size="16"></td></tr> <tr> <td width="174" align="left" class="style111"><font size="2" face="arial" class="style4">E-mail :<font color="red">* (Mandatory)</font></font></td> <td width="488"><input name="email" size="35"></td></tr> <tr> <td width="174" align="left" class="style4"><font face="arial" size="2">Age :<font color="red">* (Mandatory)</font></font></td> <td width="488"><input name="age" size="16"></td></tr> <tr> <td width="174" align="left" class="style4"><font face="arial" size="2">Sex :<font color="red">* (Mandatory)</font></font></td> <td width="488"><input name="sex" size="16"></td></tr> <tr> <td width="174" align="left" class="style4"><font face="arial" size="2">Height :</font></td> <td width="488"><input name="height" size="16"></td></tr> <tr> <td width="174" align="left" class="style4"><font face="arial" size="2">Weight :</font></td> <td width="488"><input name="weight" size="16"></td></tr> <tr> <td width="174" align="left" class="style4"><font face="arial" size="2">Structure :</font></td> <td width="488"><select name="structure"> <option selected value="Obese">Obese</option> <option value="Lean">Lean</option> </select></td></tr> <tr> <td align="left" colSpan="2"> </td> </tr> <tr> <td align="left" colSpan="2"> <font color="#000000" size="2" face="arial" class="style4"> Nature of work: Whether it involves constant traveling, etc:</font></td> </tr> <tr> <td align="left" colSpan="2" noWrap vAlign="center"><textarea cols="45" name="Nature_of_work" rows="6" wrap="off"></textarea></td></tr> <tr> <td colSpan="2" align="left"> <font color="#000000" size="2" face="arial" class="style4">Present complaints with full history :</font></td> </tr> <tr> <td align="left" colSpan="2"><textarea cols="45" name="Present_complaints" rows="6" wrap="Virtual"></textarea></td></tr> <tr> <td colSpan="2" align="left"> <font color="#000000" size="2" face="arial" class="style4"> Has the patient or his/her near relatives had such complaint? <br> (Hereditary factor) if so, furnish details in brief :</font></td></tr> <tr> <td align="left" colSpan="2"><textarea cols="45" name="Hereditary_factor" rows="6" wrap="off"></textarea></td></tr> <tr> <td colSpan="2" align="left"> <font color="#000000" size="2" face="arial" class="style4">Any cause known to you for the disease :</font></td> </tr> <tr> <td align="left" colSpan="2"><textarea cols="45" name="Known_cause_of_the_disease" rows="6" wrap="off"></textarea></td></tr> <tr> <td colSpan="2" align="left"> <font color="#000000" size="2" face="arial" class="style4">Any history of venereal disease, malaria, filaria or any other noticeable ailments:</font></td> </tr> <tr> <td align="left" colSpan="2"><textarea cols="45" name="History_of_disease" rows="6" wrap="off"></textarea></td></tr> <tr> <td colSpan="2" align="left"> <font color="#000000" size="2" face="arial" class="style4">State of Appetite, Digestion, Motion, Urine, Sleep:</font></td> </tr> <tr> <td align="left" colSpan="2"><textarea cols="45" name="State_of_digestion" rows="6" wrap="off"></textarea></td></tr> <tr> <td colSpan="2" align="left"> <font color="#000000" size="2" face="arial" class="style4">Dietary habits :</font></td> </tr> <tr> <td colSpan="2" align="left"> <table border="0" width="489"> <tbody> <tr> <td width="382"><font color="#000000" size="2" face="arial" class="style4">Vegetarian or non vegetarian food articles being taken and their timings.</font></td></tr> <tr> <td width="382"><textarea cols="45" name="Dietary_habits" rows="6" wrap="off"></textarea></td></tr> <tr> <td width="382"><font color="#000000" size="2" face="arial" class="style4">Addiction to smoking, alcohol, etc:</font></td></tr> <tr> <td width="382"><textarea cols="45" name="Addictions" rows="6" wrap="off"></textarea></td></tr> </tbody> </table></td></tr> <tr> <td colSpan="2" align="left"> <font color="#000000" size="2" face="arial" class="style4">Marital status-married or unmarried. Number of issues. <br> Menstruation, delivery, etc, problem if any:</font></td></tr> <tr> <td align="left" colSpan="2"><textarea cols="45" name="Marital_Status" rows="6" wrap="off"></textarea></td></tr> <tr> <td colSpan="2" align="left"> <font color="#000000" size="2" face="arial" class="style4">Climate & present weather conditions of the place where he/she lives.<br> Any problem of pollution of air, water, etc.</font></td></tr> <tr> <td align="left" colSpan="2"><textarea cols="45" name="Climate" rows="6" wrap="off"></textarea></td></tr> <tr> <td colSpan="2" align="left"> <font color="#000000" size="2" face="arial" class="style4">Treatment done so far</font></td> </tr> <tr> <td align="left" colSpan="2"><textarea cols="45" name="Treatment_done_so_far" rows="6" wrap="off"></textarea></td></tr> <tr> <td align="left" colSpan="2"> <font color="#000000" size="2" face="arial" class="style4">Details of Investigation/Medical Reports</font></td> </tr> <tr> <td align="left" colSpan="2"><textarea cols="45" name="Investigation_details" rows="6" wrap="off"></textarea></td></tr> <tr> <td align="left" width="174"> <font color="#000000" size="2" face="arial" class="style4">Any known Allergies :</font></td> <td align="left" width="488"> <input name="Allergies" size="30" WIDTH="150"></td></tr> <tr> <td colSpan="2" align="left"> <font color="#000000" size="2" face="arial" class="style4">Other information, if any:</font></td> </tr> <tr> <td align="left" colSpan="2"><textarea cols="45" name="Other_informations" rows="6" wrap="off"></textarea></td></tr> <tr> <td colSpan="2" align="left"> <font color="#000000" size="2" face="arial" class="style4">Blood pressure:</font></td> </tr> <tr> <td align="left" colSpan="2"><textarea cols="45" name="Blood_Pressure" rows="6" wrap="Virtual"></textarea></td></tr> <tr> <td align="right" colspan="2"> <p align="center"> <input CHECKED size="40" type="submit" value="Submit" WIDTH="40"> <input name="Clear" size="30" type="reset" value=" Clear " WIDTH="40"></td> </tr> </tbody> </table> </form> </td> <td> </td> </tr> <tr> <td> </td> <td colspan="2"> </td> <td> </td> </tr> <tr> <td> </td> <td colspan="2"> </td> <td> </td> </tr> <tr> <td colspan="4"><table width="100%" border="0" cellpadding="0" cellspacing="0" bgcolor="#DAF0FB"> <tr bgcolor="#002E5B"> <td width="100%" height="1"></td> </tr> <tr bgcolor="#efefef"> <td><table width="80%" border="0" align="center" cellpadding="2" cellspacing="1" bordercolor="000099"> <tr align="center" valign="middle" bgcolor="#efefef"> <td><p><a href="index.html" class="text"><strong>Home</strong></a></p></td> <td><a href="kerelaspecial.html" class="text"><strong>Treatments</strong></a></td> <td><a href="photogallery.html" class="text"><strong>Photo Gallery</strong></a></td> <td><a href="consultation.html" class="text"><strong><span align="center" class="activelink">Consultation</span></strong></a></td> <td><a href="ailments.html" class="text"><strong>General</strong></a></td> <td><a href="weblink.html" class="text"><strong>Web links </strong></a></td> <td><a href="contact.html" class="text"><strong>Contact us </strong></a></td> </tr> </table></td> </tr> <tr bgcolor="#002E5B"> <td height="1"></td> </tr> <tr bgcolor="#002E5B"> <td height="3"></td> </tr> </table></td> </tr> </table> </td> <td><img src="images/spacer.gif" width="1" height="14" border="0" alt="" /></td> </tr> <tr> <td><img src="images/spacer.gif" width="1" height="68" border="0" alt="" /></td> </tr> <tr> <td><img src="images/spacer.gif" width="1" height="97" border="0" alt="" /></td> </tr> <tr> <td><img src="images/spacer.gif" width="1" height="94" border="0" alt="" /></td> </tr> <tr> <td><img src="images/spacer.gif" width="1" height="87" border="0" alt="" /></td> </tr> <tr> <td><img src="images/spacer.gif" width="1" height="13" border="0" alt="" /></td> </tr> </table> </body> </html>