Name
Address
E-mail
Phone
Fax
Age
Sex
Weight
Height
Nationality
Name of the disease or
problem according to modern diagnosis >>
Main
symptoms and chief complaints >>
You
should furnish all the main problems you have and for how long they
have been. In case of problems which are not permanent and come only
sometimes, you should mention in details how they start. Is
there any relation with specific diet, foods, tension etc.? Try to
provide the details about the symptoms.
History of the disease and
other symptoms, if any >>
You
should give all the details about the history of the disease
including the family history of the disease, if any. You can mention
all those symptoms, which you feel are not the main ones but bother
you now and then.
Time of the
day when you usually go for evacuations Frequency Color of the
stool Consistency Whether foul
smelling Regular or
irregular Do you tend to
be constipated? Any other
details or observations
Diet
>>
It would be nice if you describe your diet in your own way. You can take some help from following questions, if
you are not able to explain the diet.
Kind of food
usually taken: Breakfast, Lunch, Dinner Are you
vegetarian? If no, how often you eat meat, fish or other kind of
non-vegetarian. Do you take
snacks/foods in between your main meals? If yes, what? How often do
you eat cooked foods or raw foods? Do you use
spices? If yes, what kind and how much? Quantity of
tea, coffee, alcohol, or any other kind of stimulating drinks
taken in a day? How often do
you eat fast foods, fried and frozen foods? How much water
do you usually drink in a day? Quantity of
milk products and sweets and their kinds All other
details about your diet?
Urination
and sweating >>
Frequency of
urination Quantity of
urine Color of urine Is there any
burning sensation while passing urine? Did you make
recently a urine investigation? If yes, what are the findings? Any other
specific symptoms relating to the urinary system Quantity and
smell of sweat or any other details relating to sweating
Appetite and digestion
system >>
How is your
appetite? Do you have
problem like heaviness, feeling weak and lethargic immediately
after meal? Do you have
any pain in the stomach area, specially after eating or on empty
stomach? Please specify the area of pain. Do you have
wind or gas? Do you
over-eat? Are your
eating habits regular or irregular? What kinds of
food bother you and which ones are OK? Explain in details what
kind of troubles you get.
Mental nature and the
nervous system >>
What
kind of mental nature do you have?
Are you always
tensed, anxious, or stressed and what causes this? Is it related
to your activities or climatic conditions? How is your
sleep? Is it deep, sound or disturbed? How many hours
do you usually sleep? Please mention the timings of going to bed and
waking up. What emotions
are prominent in your character? Do you think
your disease has some relation to you being nervous, stressful,
fearful etc.? Do you find any change in the symptoms under such
conditions? What kind of
habits / hobbies do you have and which ones do you enjoy the most? Any other
details about your mental nature or nervous system
Exercise>>
Do you
exercise regularly? Any other
details
Climate and environment >>
Describe briefly the type of climate and
environment in which you live. Do you associate
the symptoms of your disease with any certain type
of climate? Do
the symptoms diminish in any particular climate or
environment?
Atmosphere
at work, in your family and society >>
Are
your disease or symptoms related or affected by the atmosphere at
your work, in your family or society?
Any
other details, suggestions or indications that you might feel would
help in making an Ayurvedic diagnosis? >>
Have
you ever made an Ayurvedic constitution test? If
yes what were the results? >>
Reports
of any other clinical investigations, if made >>
Medications
/ treatments / remedies taken against the disease and their effects
in brief? >>
