Submit Patient History

Patient History Form

Name

Phone

Age

Gender

In which part of the body are you describing your problem ?

Describe your symptoms of the medical problem you are facing ?

Since when are you facing these symptoms ?

Recently It has been some time From Long Time

Have you consulted anyone before ?

Yes No

How many times in a day do you experience your above mentioned symptoms in a day?

How strong are the symptoms

Mild Acute (Meaning : Very Strong)

Do you feel loss of energy?

Yes No

Have you lost weight in recent past?

Yes No

Do you feel any anxiety, nervousness or any other mental illness ?

Yes No

If you have your blood test reports / or any other reports, please mention the results of the test.

Upload your medical Reports (upto 100 MB)

What Medicines are you taking presently?

Do you have any other disease (like Diabetes, Hypertension, Arthritis etc.)

Mention the details of details previous illnesses you have suffered in the past:

Do you have any other information to share? Or do you have any other questions and queries?

Ayurveda is an ancient health care tradition that has been practiced in India for at least 6,000 years. The word comes from the Sanskrit terms ayur (life) and veda (knowledge).

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+1-416-804-1500
+1-647-276-1111
info@bestayurveda.ca
drharishverma@gmail.com
Best Ayurveda Ltd. 2250 Bovaird Drive East Suite 316, Brampton Ontario, L6R0W3, Canada

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