Product Order Form

Thank you for your interest in ordering Kayakalpa products. In order to ensure that your selection is customized to best fit your requirements, we need some information to determine your basic constitution.

Once you have filled this out we will send you an email so that you may complete your order.

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Name
Age
DOB (mm/dd/yy)
Address
City
State
Zip
Home Phone
Work Phone
Email
Occupation
Marital Status
What are your reasons for seeking KayaKalpa?
What is your significant medical history and what are your current concerns?

You are active, often restless and have a dry, lean body.You rarely sweat and have irregular apetiite, digestion and elimination. Your mental state is curious, questioning,and often indecisive. You tend to be talkative and enjoy travelling and stimulation.Overall your mental, physical and emotional nature is variable.



You may be prone to one or more of these symptoms: Anxiety, constipation, joint and muscle pain, arthiritis, chronic fatigue, migraines, low sexual drive and disorders of the nervous system.



You tend to be inward and set in your habits.Your skin is oily, smooth and cool to the touch, your apetite and digestion and elimination is regular but sluggish. Sleep is deep and long with a tendency to oversleep sometimes.You are gentle, tranquil and calm. Overall, your mental, physical and emotional nature is stable.



You may be prone to one or more of these symptoms:Depression, Weight gain, asthma, bronchitis, allergies sinusitis, chronic coughs and colds.




You are exuberant and passionate and can also be impatient and irritable. Your skin is warm, moist and sensitive and you sweat profusely. Your apetite is strong and digestion and elimination regular. You fall asleep easily and wake up alert.Overall, your mental,physical and emotional state is characaterized by intensity.



You may be prone to one or more of these symptoms: Anger, inflammation, Psioriaris, acne, rashes and other skin diseases.