Patient History form for : Amavata (Rheumatoid Arthritis)

Name : *

Age : *

Gender *
 Male Female

Address :

City : *

Zip Code : *

Country : *

Phone Number : *

E-mail : *

Since when are you suffering from pain in the joints ?

In which joints do you have pain ?

Is there any crackling sounds in joints during walking, climbing stairs ?
 Yes No

Is there any redness on the joints ?
 Yes No

What diet and atmosphere or climate aggravates your pain ?

Is there any stiffness in the joints ?
 Yes No

Is there any swelling around the joints ?
 Yes No

Is there any difficulty while sitting on the floor ?
 Yes No

Do you suffer from any other disease like High Blood Pressure, Diabetes, or Heart Disease ?
 Yes No

Do you exercise regularly ?
 Yes No

Do you use any pain killer medicines ?
 Yes No

Do you have any tests reports done ? If yes then kindly upload reports. (10 MB Maximum File Size.... Preferably send zip files. If you have more files then email separately to

Do you have any current medication going on ? If yes then describe below

If you have any other information to share then please describe below :

Fatal error: Call to a member function get_cart_contents_count() on a non-object in D:\Hosting\8729953\html\sushruta\wp-content\plugins\woocommerce-woocart-popup-lite\templates\frontend\popup_content.phtml on line 5