Consultation Form

Patient Medical History

Prefix

First Name *

Last Name *

Suffix

Birth Date

MM 010203 12 DD 010231 YYYY 19601970 198019902000 2025

Age *

Gender * Please select Male Female Other

Describe briefly your present symptoms *

Please list the names of other practitioners you have seen for this problem:

Current Medications

Any Major Hospitalizations (include where, when, & for what reason): *

Drug allergies:

Yes No

To what?

Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements:

Drug 1:

Drug 2:

Drug 3:

Drug 4:

Drug 5:

Dosage 1:

Dosage 2:

Dosage 3:

Dosage 4:

Dosage 5:

Past Medical History

Do you now or have you ever had: *

Diabetes Heart murmur Crohn’s disease High blood pressure Other...

Please specify

Personal History

Were there problems with your birth?

Yes No

Please specify

Medical File Upload

Medical File Upload 2

Purpose of Contacting Padma Ayur Varma Nilaym

Please check the appropriate box(es): *

Inquiry Consultation Medicines Marma Chikitsa Appointment

Contact Details

Email *

Phone *

WhatsApp / Telegram App No

Street Address *

Address Line 2

City *

State / Province / Region *

Postal / Zip Code *

Country *

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