forms | DrAbhiram’s Ayurveda

First name

Last name

Email

Phone

Address

How long have you been experiencing back pain?

Where do you feel the pain most?

Is the pain localized or does it spread to other areas?

What aggravates your pain?

Does the pain reduce with rest?

Are there any associated symptoms ?

How often do you engage in physical activity?

Daily

Weekly

Rarely

Never

Do you sit or stand for long hours at work?

Yes

No

Do you have any habits that may affect your back health?

Yes

No

Do you use ergonomic support (chairs, cushions, etc.)?

Yes

No

Have you consulted a doctor for this issue before?

Yes

No

Have you undergone any diagnostic tests? (MRI /X-RAY)

Yes

No

Have you taken any medications or treatments for your back pain?

Yes

No

Upload if MRI Scan report available

Signature - Consent I hereby agree to participate in the back pain screening camp organized by Dr. Abhiram’s Ayurveda. I understand that the information provided will be used solely for diagnostic purposes.

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BACK PAIN SCREENING CAMP

Fill this form for Registration

Know Your Prakruthi