Patient History
Form

Patient History Form

PATIENT HISTORY FORM

Describe your medical condition below. Our doctors will contact you soon.

Name

Phone Number

Age

GenderMaleFemaleOther

Street Address

Address line 2

City

State

Postal Zip code

Country

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

Describe your symptoms of the medical problem you are facing ?(optional)

Since when are you facing these symptoms ?RecentlyIt has been some timeFrom Long Time

Have you consulted anyone before ?YesNo

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

How strong are the symptomsMildAcute (Meaning : Very Strong)

Do you feel loss of energy?YesNo

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

Click to Upload Medical Reports - File 1

Click to Upload Medical Report - File 2 (Optional)

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?

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Dr. Harish Verma (BAMS Gold Medalist), founder of Sushruta Ayurvedic Therapy Center has helped people with chronic illness with Ayurvedic and Alternative treatments that he has gathered with more than 35+ years of experience.

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Our Specialities

Acid Reflux (GERD)
Acne or Pimples
Arthritis
Crohn’s Disease
Rosacea

REACH US

Sushruta Ayurvedic Therapy Center A-138, Madhuban Enclave, Behind Nirman Vihar New Delhi – 110092
info@sushruta.com
+91 99106 72020
011 4244 5009
Open Mon - Sat 10 AM - 6 PM (Sunday Closed)

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