For consultation and discussion, please fill in the following data correctly (by filling in this form you automatically declare that the data filled in is in accordance with the facts / facts)
Pejawan Intr. Village (English)
Kind of Healing Program
Client name
Couple name
Adress
City
Occupation
Gender
Man
Women
Birth date
General Assesment/
/
Height
Wight
Are you pregnant or milking?
Yes
No
Age of pregnancy or milking
Daily routine activity
Chief complain
Begining time
Medical diagnose
Conditions, activities or food that trigger it
Treatment/ Therapy has taken
Duration of treatmen/therapy
The result of treatmen
Last week dietary habbit
Most vegetable taken in last week
Most fruit taken in last week
Main meals taken in last week
How often did you eat @resto in last week
Wich one more prefer
Hot drink
Cold / Ice drink
What condition is your urine? What colour?
What condition of your fases?
Which one more often?
Stiflingly hot
Freezing
Get an influenza / Cough now?
Yes
No
Wheather condition in last week
Past Medical HistoryOther desearse suffered
Since when did it suffered
Have you ever had a fall/accident? Like what?
Have you ever had surgery? what kind?
ReferenceVocher code
Referencing name
Special status
WA number the one that referencing
DATA FOTO
Please also send a photo for a fitrah health assessment:
1. a Clear photos of the tongue (must have)
2. Photo of the body part that is complained about (must have)
3. X-ray photos (optional)
4. Photos of lab results (optional)
5. Photo of previous medicine/herbs (optional)
Send photos by clicking the following button:
Still confused and need further consultation??
Contact the Pejawan International Village Admin by clicking the button below:
Thank you for contacting PEJAWAN Intr. Village
God willing, the admin will contact you again soon.
Disclaimer: There is no guarantee of 100% recovery from the recommended treatment. We must believe that absolute healing only from Allah swt / Almighty God
Be patient if God has not yet healed, and be grateful if God is willing to heal through the endeavors we do.
May you always be healthy and full of blessings
Alamat
082122688808
082122688808
Umrohhajigemilang@gmail.com
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@2025 Pejawan Holistic Eduhealth Center Inc.