Name
Address
E-mail
Phone
Fax
Age
Sex
Weight
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 problems which are not permanent and only come
sometime, you should mention the details they start ? Is there is some
relation with some 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 family history disease, if any. You can mention all those
symptoms, which you feel are not the main symptom which bother you
now and then
Time of the
day when you usually go for evacuations Frequency Color of the
stools 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
language. 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? Do you often
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 drinks taken in a day? How often do
you eat fast foods, fried foods 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?
Urinary and other excretory systems.
Frequency of
urine. Quantity of
urine. Color of
urine. Is there any
burning sensation while passing urine? Did you make 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 that ?
Appetite and digestion
system
How is your
appetite? Do you have
problem like heaviness, feeling weak and lethargic immediately after 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? How are your
eating habits? Regular or irregular? What kind of
food bother you and which ones are OK? What kind of trouble do
explain in details?
Mental nature and the
nervous system
What kind of
mental nature do you have? Are you always
in tension, anxiety, or stress and what causes this? Is is related
to your activity or climatic condition? How is your
sleep? Is it deep, sound sleep or disturbed? How many hours
do you usually sleep? Please mention the timings of going to bed and
waking up. What emotions
would you generally describe to be prominent in you character? Do you think
your disease has some relation to your being nervous, stressful,
fearful etc? Do you find any change in the symptoms under such
conditions? What kind of
habit/ hobbies do you have and which ones do you enjoy the most? Any other
details about your mental nature or the nervous system?
Do you
exercise regularly? What kind of
exercise do you do and how often? At what time
of the day do you usually exercise and what are the surroundings? Any other
details?
Climate and environment
Describe briefly the type of climate and
environment in which you live? Do you have
association between the symptoms of the disease
and a certain type of climate? Do the symptoms
decrease in a particular climate or environment?
Atmosphere at the job,
family or the society
Does your disease or symptoms have any relation or
affect by the atmosphere at your job, family or
society?
Any other details,
suggestions or or indications that you have
might feel would help in making Ayurvedic
diagnosis?
How you ever made an
Ayurvedaic constitution test? If yes what were
the result?
Reports of any other
clinical investigations, if made?
Medications / treatments /
remedies taken for the diseases and their
effects in brief?
