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Phone Number Age SexMaleFemale Weight 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 Bowel Movements * 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. 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 system * 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? Exercise * 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?
