vedi herbals

Generate Prescription

Subject *

Patient's Name *

Your Email ID *

Phone Number *

Address

Present Illness (How did it start , duration etc.) *

Upload existing prescription (Size should not be more than 2 MB) *For Cannabis based medicines, proof for disease diagnosis (i.e. Doctor's prescription, report) is mandatory

History of past illness (if any)

Family History (Does any of your blood relation suffer from similar illness)

Drug History ( Do you use any drug, alcohol or tobacco habitually ) *

Age *

Sex *Male
Female

Marital Status

Heart Rate

Blood Pressure (in mmHg) *

Height (in feet and inches)

Weight (in kilograms) *

Blood sugar (in gm/dl)

Profession

Rate your sleep on the scall 1 to 5

Bowel habit

Urine

Sleep Habit

Do you dream

Appetite *

Diet habits *

Thrist *

Do you have any experience of using cannabis in any form?

Are you allergic to any drug, antibiotic or any other supplement? *

Current Medication, If any

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Confidentiality Notice: All information in this personal Health Care Record is strictly confidential, that is legally privileged.