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Full Name
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Name
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Year
I Am
*
Male
Female
Basic Information
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
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Aruba
Australia
Austria
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The Bahamas
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Chad
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Mali
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Montserrat
Morocco
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Netherlands Antilles
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Nigeria
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Mobile Number
*
E-mail
*
Occupation
*
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Service - Table Work
Service - Touring Job
Profession
Housewife
Student
Main Case Paper
Your Weight in KG
*
Main Complaints
*
Factors - Increasing / Decreasing Symptoms
*
Previous Illness History
*
Any Surgical History?
*
Yes
No
If Yes...Give Details
*
Family History
*
Routine ( Dinacharya )
Wake up
*
Before Sunrise
After Sunrise
Excercise?
*
Daily
Sometimes
Never
Type of Job
*
Hectic Job
Stressfull
In Air Conditioned
In Hot Surrounding
Shift Duty
Night Duty
Continuously in Front of PC / Laptop
Travelling Job
House Work
Your Appetite?
*
Good Appetite
No feeling of Appetite
Some Times Good Some times No Feeling of Appetite
Your Timing of Having Meal..
*
Reglar
Irregular
Only After feeling of Appetite
Scheduled as per Timing
Other
Do you have Breakfast?
*
—Please choose an option—
Yes
No
Sometimes
Breakfast Timing
*
Morning
Evening
Both Times
None
Do You Feel Hungry @ Breakfast
*
Yes
No
Do not Take Breakfast
Timing of Lunch
*
—Please choose an option—
10.00 AM - 11.00 AM
11.00 AM - 12.00 PM
12.00 PM - 02.00 PM
Before 10.00 AM
After 02.00 PM
Timing of Dinner
*
—Please choose an option—
Before Sunset
07.00 PM - 09.00 PM
09.00 PM To 10.00 PM
10.00 PM Onwards
Very Irregular
Bad Habbits
*
Cigarette
Tobacco Chewing
Gutkha
Alcohol
Use of Masheri
None
Details about Bad Habbits ( Quantity, How Many Times etc...)
*
Maximum Consumption of
*
Sweet Food
Sour Food
Salty Food
Bitter Food
Pungent Food
Stringent Food
Detail Routine ( Detail Dinacharya )
Daily Food Chart
*
Daily
weekly
sometime
Never
Hotelling
Daily
weekly
sometime
Never
Chinese
Daily
weekly
sometime
Never
Curd
Daily
weekly
sometime
Never
Pickle
Daily
weekly
sometime
Never
Papad
Daily
weekly
sometime
Never
Flakes (Poha)
Daily
weekly
sometime
Never
Fried Food
Daily
weekly
sometime
Never
Sprouted Food
Daily
weekly
sometime
Never
Bakery Products
Daily
weekly
sometime
Never
Misal / Vada-paav / Samosa / Kachori etc.
Daily
weekly
sometime
Never
Fermented Food (Idli/ Dosa/Uttapa etc.)
Daily
weekly
sometime
Never
Gram Food ( Besan Atta Foods)
Daily
weekly
sometime
Never
Bhel / Panipuri / Ragada pattis etc.
Daily
weekly
sometime
Never
Stale Food (Baansi Cheeze)
Daily
weekly
sometime
Never
Milk Products
Daily
weekly
sometime
Never
Sago (Saabudaanaa)
Daily
weekly
sometime
Never
Fasting (Langhan / Upvaas)
Daily
weekly
sometime
Never
Raw Food (Uncooked Food)
Daily
weekly
sometime
Never
Nonveg
Daily
weekly
sometime
Never
Bowel Habbits
*
Yes
No
Sometimes
Do you visit Toilet Daily
Yes
No
Sometimes
Do you have feeling of Daefication
Yes
No
Sometimes
Do you need Tea / Coffee / other things for Sensation
Yes
No
Sometimes
Nature of Stool ( Tick which is Applicable )
*
Solid
Semisolid
Watery
Sticky
Yellowish
Dark Yellowish
Brownish
Geenish
With Blood
Urine Frequency
*
2-3 times in 24 Hrs.
4-6 times in 24 Hrs.
More than 6 times in 24 Hrs.
More in Day Time & Not During Night
Sometimes during Night Also
Always during Night Also
Other
Sweating / Perspiration
*
—Please choose an option—
Continuous sweating Round the Year
Only in Summer
More Than Others
Just After Physical Work
Profuse with Smell
Stains Cloths
More on Palms
About Your Sleep
*
Sound sleep in Night
Breaking Sleep
Other
Do you Have Afternoon Sleep After Lunch?
*
—Please choose an option—
Yes
No
Sometimes
Stress Level
*
1
2
3
4
5
6
7
8
9
10
Very Less
1
2
3
4
5
6
7
8
9
10
Too Much Stress
Gyanaecology - Fields for Female Patients Only
Your Menstrual Cycle ( In Case of Females Only)
3 Days / After 28 Days
less than 3 Days / After 28 Days
4-6 Days / after 28 Days
3-5 Days / After more than 30 days
3-5 days / Before 28 Days
Other
Complaints During / Before / After Menstruation
Obstretic History( History Regrding Delivery)
Any History of Abortion / Misscarriage ?
Yes
No
If Yes to Abortion / Misscarriage, How Many Times
Finalise your Submission
Did you Take Ayurvedic Medicines for This / Other Illness?
*
Yes
No
If yes, Give Details with Medicines
Are you Ready To Follow Do's & Dont's ( Parhej / Pathya-Apathya) Strictly adviced by vaidya?
*
Yes...Ofcourse
No...Never
I will Try my best
Do you Have Any Reports / Scanned Reports?
Do you need Bill For your Payment
*
Yes
No
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