Personal Details Name
City
Email
Phone
Age
Gender Male Female
Height
Weight (Pounds)
Occupation
Details of your home climate
Health Details Name your disease (as diagnosed by conventional/modern medicine)
What are the chief signs, symptoms or complaints that made you to look at Ayurveda as an alternative health solution?
General Diet Diet details
Complete History of Disease Do your symptoms/complaints decrease or increase when you change climatic zones?
What kind of food, lifestyle or environmental changes relieve the nature of your complaints?
What kind of food, lifestyle or environmental changes trigger the symptoms of your disease?
Digestive System How is your appetite and digestion?
Give complete details of your bowel movements, such as time of evacuations, frequency, color, consistency, regularity, irregularity and smell.
Do you see any mucus in your stool? Yes No
How often do you have constipation and what do you think are the causes?
Do you pass wind?
Do you have acid reflux/heartburn?
Do you experience heaviness, discomfort or pain in the stomach after eating?
What is the frequency, quantity and color of your urine?
Do you feel any burning sensation while urinating? Yes No
Do you sleep soundly? Yes No
How would you rate yourself emotionally? Anxious Nervous Depressed Worrisome Tense
How do you perceive your own financial status? What are your comfort levels with your current situation?
Treatment History What types of treatments and medicines have you taken so far?
What have been the results?
Have you observed any side-effects?
How much do you know about Ayurveda?
