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Assessment Form

    Personal Health Information - Medical History

    Your Name (required)

    Age :

    Gender :




    Postal code


    Phone no



    Weight (In Kg or Pounds)


    Name of your Disease ( As Diagnosed by Medical Consultant )

    Chief Complaint About Your Problems

    Signs or Symptoms

    How long you are suffering from (Years Months Days )

    For Skin Problems - Which Areas have Affected

    For Skin Patients (Do You Feel Pain, Itching, Any Blood Or Watery Discharge From Lesions )

    Dietary Details ( About your Breakfast, Lunch & Dinner )

    Your Food and life style habits ( Veg, Non-Veg, Overeating, Less-eating etc. )

    Any food or weather Increase or decrease your problem

    Presently On Medicines ( Write the name of medicines presently you are taking & from How long )

    Are you Suffering from any other health problem (Diabetic , Hypertension , Heart Problem , Any Other Disease etc)

    Appetite (Normal , Low , High)

    Bowel Movements ( Like Acidity , Constipation , Normal , Regular , Irregular , Other Problems Etc.)

    Urinary System ( Color of Urine , Frequency ,Burning Sensation )

    Sleep ( Sound , Normal , Disturbed , Insomania )

    Mental/ Emotional Condition ( Anxious, Nervous , Worrisome , Depressed ,Tense , Relaxed , Irritable ,Impatient , Patient , Calm ,Lethargic , Energetic, Restless )

    Previous Medical History ( Have you been treated for any other disease previously )

    Results of that treatment

    How do you find us ( Google Search , YouTube , Google Ads ,FaceBook , Friend's Suggestion , Any Social Media )

    Anything more you want to tell about your health problem

    You May Write your Problems in Details if you want to tell our Doctors more about your health issue.



    Super Specialty Ayurveda, Ayur-Sudha is a Holistic Centre devoted to Ayurvedic Treatment & research run by a highly qualified group of professionals.


    Our Ayurvedic Clinic has clients visiting from Markham, Vaughan, Toronto, Caledon, Brampton, Mississauga, Oakville, Guelph, Burlington, Kitchener, Milton and Hamilton, ON.


    Important – Please read this information and accept all term and conditions. 

    – By filling all the details and sending us the assessment form / filling details on the consult now link meaning that you are giving consent for the consultation and treatment. You are abide by the term and conditions for the consultation and treatment. Your entire information will be kept confidential. This consultation and natural medicines services may include – Ayurveda, Healthy living, Homeopathy medicine, Western and Eastern Herbal Medicines, Healthy lifestyle, Holistic Counselling.  The information which you are sending to us is to understand your health and health issues. We assume that the information you are proving is true and nothing has been concealed or  false. This assessment helps us to determine which Herbal, Herbs or Natural Health Product will be best suited for the individual needs of the person whose information is being sending to Ayur-Sudha. 

    The services offered by Ayur-Sudha does not involve allopathic diagnosis, prognosis, treatment, cure or prescribing allopathic medicines/drugs or any acts for which will allopathic license is required. You understand in case of a serious illness you should see your Allopathic Doctor/MD. Consult Ayurvedic Doctor Online Canada.

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