Ayurvedic Case Diagnosis Form

Gathers a patient's full medical history, daily routines, and symptoms so an Ayurvedic practitioner can reach a diagnosis.

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Full Name

Nombre

Apellido

Birth Date

I Am

Male Female Other

Section

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Mobile Number

E-mail

Occupation

Section

Your Weight in KG

Main Complaints

Factors That Increase or Decrease Symptoms

Previous Illness History

Any Surgical History?

Yes No

If Yes, Please Provide Details

Family History

Section

Wake-up Time

Before 6 AM 6-8 AM After 8 AM

Do You Exercise?

Yes Sometimes No

Type of Job

Sedentary Physical / Active Mixed

How Is Your Appetite?

Poor Normal Excessive

How Regular Is Your Meal Timing?

Regular Irregular

Do You Have Breakfast?

Breakfast Timing

Before 8 AM 8-10 AM After 10 AM

Do You Feel Hungry at Breakfast?

Yes No

Timing of Lunch

Timing of Dinner

Bad Habits

Smoking Alcohol Chewing Tobacco None

Details About Bad Habits (Quantity, Frequency, etc.)

Highest Consumption of

Spicy Food Sweet Food Salty Food Fried Food

Section

Nature of Stool (Check What Applies)

Normal Loose Constipated Alternating

Urine Frequency

Normal Frequent Infrequent

Sweating / Perspiration

About Your Sleep

Sound Disturbed Insomnia

Do You Nap After Lunch?

Section

Your Menstrual Cycle (Females Only)

Regular Irregular Menopause Not Applicable

Complaints During / Before / After Menstruation

Obstetric History (Delivery History)

Any History of Miscarriage/Abortion?

Yes No

If Yes, How Many Times

Section

Have You Taken Ayurvedic Medicines for This or Another Illness?

Yes No

If Yes, Please Provide Details and Medicines

Are You Willing to Strictly Follow the Do's and Don'ts (Parhej / Pathya-Apathya) Advised by the Vaidya?

Yes No

Do You Have Any Reports or Scanned Documents?

Max 10 MB per file

Do You Need a Receipt for Your Payment?

Yes No

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Ayurvedic Case Diagnosis Form

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