Patient History form for : Sandhivata (Osteoarthritis)

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 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 drharishverma@gmail.com)

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 :


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