The same questionnaire is used for both e-consultation as well as consultation in person
ALL THE INFORMATION THAT YOU ARE ABOUT TO GIVE WILL BE KEPT STRICTLY CONFIDENTIAL
If you feel that any of the information is too personal or you do not feel comfortable to write here, please feel free to leave that section blank. Thank you.
If you write in computer: mark your answers with an underscore or highlight them:
eg:Which colour are your eyes: brown blue green grey
Do you drink coffee: Yes No
Please read these important instructions before completing the questionnaire:
Place and Date of first appointment:
If you were referred by someone, please mention their name: ______
Your details:
Name
Sex
AgeMarital status ______(Husband / Wife / Partner)
Occupation:
PLEASE GIVE COMPLETE AND CORRECT DATA FOR MEDICAL ASTROLOGICAL EVALUATION. IF YOU ARE NOT SURE OF ANY OF THE DATA PLEASE MENTION IT.
Date, Month and Year of birth:
Time of birth (in 12 hr format):
Place of birth (city and country):
(if there are two cities by the same name, then mention the state as well):
Latitude & Longitude of the place of birth (if you know):
Permanent residential Address
E mail
Phone number
Please attach a photograph of yourself (optional, but still it is easier to remember a name with a face)
Dimensions:
Height:Weight:
Arm width:
(Arm width is the distance, from the tip of your middle finger of one hand to the other, when you stand with arms stretched out on both sides)
Chief complaints for which you have come for consultation: (there is nothing like major or minor complaints. ALL complaints are helpful to understand the underlying pathology)
WHEN YOU MENTION YOUR COMPLAINTS PLEASE DO NOT WRITE ONLYTHE DIAGNOSIS. YOU NEED TO WRITE THE SYMPTOMS YOU ARE FEELING/EXPERIENCING AND NOT YOUR DOCTOR'S MEDICAL DIAGNOSIS. Your doctor's diagnosis is to be written in the next question.
If you can write the symptoms in chronological order it will be very helpful to map the progression of your imbalance.
Complaint / Symptom / When it started & Duration / Any other details you like to addNote:
If you have any investigation reports (blood tests, x rays, MRI etc) done earlier please scan/photograph and attach a copy of the same. (language does not matter)
If you are coming for a physical consultation, please carry all previous health records and investigation reports (only if you have not emailed it)
In cases of physically visible problems, it is advisable to attach a photograph of the affected part.
Your physician’s diagnosis(if any):
Any treatments / medicines you have received in the past OR are receiving at the present time:
1.
2.
3.
Describe the course of present illness/ symptoms from the beginning to the present time in your own words:
Is there any specific factor that you feel contributed significantly to your illness?
Past illnesses / surgery: (Write about any past illnesses you have experienced and treatments taken)
Childhood diseases (if any):
Illnesses in Family:
Take a while to look at your body. Are there any prominent moles on any specific body parts? Please enumerate with exact location.
Have you experienced any unexplained and spontaneous quivering or twitching of any part of your body from time to time? If yes, which?
You can also send me a scan or clear photograph of your palm for Medical Palmistry. (optional)
Please take a clear photograph of your tongue fully projected out, in natural sunlight and send it to us along with this questionnaire.
Life style:
Daily routine: (describe a typical day in your life)
What do you do for recreation?
What are your hobbies?
Any Daily exercise/ yoga (describe Frequency and duration also) :
Most healthy/ favourite season of year
Most unhealthy/difficult season of year
Bowel movement (stool):
Loose / Constipation / Hard / Blood / Mucus / Difficulty or straining / alternated loose and constipation
What is the colour of the stool? Dark brown / Yellowish / Pale whitish
Does the stool float or sink in the toilet?
Is the stool well formed (like a banana) or fragmented?
Is there much foul smell of the stool?
Do you observe any undigested food in the stool?
Do you need to go to the toilet soon after eating?
Do you need to strain to pass stool? Is there any mucus or blood in stool?
Urine:
Which of these words describe your urine?
Dark / Pale / Turbid / Painful / Scanty / Difficult / Frequent / Dribbling / Incontinence / Blood in urine/ Burning sensation
Do you wake up at night to use the toilet? How many times?
Is there foul smell in the urine?
Food:
How is your Appetite? (whether you emotionally feel like eating)
How is your hunger? (whether you physically feel like eating)
(Appetite is in the head (mind) – whether you feel like eating / and hunger is in the stomach. One may be hungry but still have no appetite. One may feel like eating but may not be really hungry.)
Do you eat fast or slow?
How much water do you drink in the day? (not juice or tea)
Your favourite foods:
Your favourite taste: Sour / Pungent / Sweet / Bitter / Salty
How is your digestion? Do you have Bloating / Gas?
Do you still have a full stomach 45-60 minutes after your meal? Is it food or is it just gas?
Your Present Diet: (indicate times of day and food items)
Time / Food itemsBreakfast
Lunch
Dinner
Snacks / Others
Any food intolerances (eg. lactose, gluten, specific foods)
Any allergies
Has there been increased weight gain or weight loss in recent months or years?
Any difficulty with eyes(vision)/ears(hearing)/nose(smell)/tongue(taste)/skin(touch, temperature)
Any Breathing difficulties? Congestion or mucus in lungs?
Any back/body/joint pains?If yes, describe the location and nature of the pain. (sharp, cutting, pricking, burning, dull, aching, crushing)
What is the duration of pain: Continuous / Intermittent
If pain is on the back, at what level of back: (cervical, thoracic, lumbar, sacral) – Indicate exact level if possible
Sexual history: (sex is one of the pillars of health in Ayurveda)
Do you have a normal libido?
Any history of sexual problems diagnosed or experienced by yourself?
Frequency of sexual activity (per week or month):
Do you have any of the following: yes/ no
premature ejaculation / painful sex (dyspareunia) / dryness in vagina / dissatisfaction with sexual life
Emotional assessment:
Most predominant emotion in life:
Anger / Excitement or Joy / Chronic worry or Pensiveness / Sadness / Fear / Possessiveness
Any particular intense emotional event in the recent past:
Any difference/change in life style before the start of present disease:
Is there tendency to by easily startled?
Propensity to worry / anger / Mental restlessness / Severe timidity / Inappropriate laughter
Depression / Anxiety / Irritability
- How do you describe yourself emotionally?
- Are you emotionally satisfied in life?
Voice:
Loud / Weak / Nasal / Snoring / Stuttering / Hoarse / Muffled / Crying /Sharp
Speech:
How do you describe yourself? (Very Talkative / Talkative / Always come to the point quickly /Few words /Silent)
Sleep:
Sleeping time:
Waking time:
Dreams: (yes / no)
If yes, then are they –
- fearful / purposeful / peaceful / cannot remember
- Having lot of movement / Doing something very specific / Something static and dull
- Any other ?
Quality of sleep: (do you feel rested when you wake up?)
Do you fall asleep within 15 minutes of lying in bed?
Do you wake up during the night? Why?
Direction of head while sleeping:
Spiritual assessment:
Do you have any spiritual practices?
Do you meditate regularly?
Menstrual history: (for females)
Pregnant? Yes / No
Taking Birth control pills (P-pills) at present? Yes / No
Birth control pills (P-pills) in the past? Yes / No
If yes, for how many years? From what age did you start? For medical or personal reasons?
Age when you had your first period?
Date of Last menstrual period (LMP)?
Cycle length (ie..Number of days between each cycle): ______
Is your cycle regular? ? Yes ? No
Describe your flow: ? Heavy ? Light ? Average
How many days does the flow usually last?
How many sanitary pads do you require to change in one day?
Color of your flow: ? pink ? bright-red ? dark-red ? purple ? brown ? black
Do you have large clots in menstrual blood? ? Yes ? No
Do you have cramps during/before menstruation? ? Yes ? No
Do you have spotting outside of your menstrual flow? Yes /No
Do you have any of the following Pre-menstrual symptoms?
? Breast tenderness
? Irritability & mood swings
? Acne breakouts
? Headaches
? Bloating
? Fatigue
Please list any other menstrual symptoms you may have:
Is there a history of contraceptive pills or any other medications taken to alter your menstrual cycle?
Please circle if you (use / have used) any of the following: Cigarettes / Alcohol / Drugs / Mood enhancers
Which is/are the most stressful area/s of your life?
Work / Family / Health / Education / Personal relations / Recreation / Finance
Are you going through a stressful period in your life now? Have you been through a very stressful period recently? Please tell us about it. (Note: Stress is the root cause of all illness)
OPTIONAL:
If possible you may send us the scan of the drawing of your place of residence (a rough hand drawing will also be sufficient) indicating the four directions and rooms. It can help in diagnosis in certain cases.
(Note: Each direction has a specific energy and it influences your physical and mental health)
Please check off any of the following symptoms you are experiencing:
1
Eyes, Ears, Head, Neck
? Dizziness
? Fainting
? Enlarged lymph glands
? Migraines/headaches
? Ringing in the ears (tinnitus)
? Decreased hearing
? Earaches
? Blurry vision
? Spots/floaters
? Dry eyes
? Eye pain
? Poor night vision
? Red, burning, itchy eyes
? Other: ______
Cardiovascular
? Rapid heartbeat
? Chest pain/tightness
? Irregular heartbeat
? Swollen ankles
? Poor circulation
? Hypertension
? Hypotension
? Other: ______
Respiratory
? Chronic cough
? Coughing up blood
? Coughing up phlegm
? Shortness of breath
? Wheezing/Asthma
? Frequent colds & flu’s
? Other: ______
1
Nose, Throat, Mouth
? Bleeding gums
? Sinus infection
? Hay fever allergies
? Swollen glands
? Difficulty swallowing
? Bitter taste in mouth
? Tongue/mouth ulcers
? Nose bleeds
? Dry mouth/thirst
? Other: ______
Muscles & Joints
? Joint pain
? Body aches/stiffness
? Weakness in muscles
? Spinal curvature
? Numbness/tingling
? Heaviness in body
? Backache or knee pain
Other: ______
1
1
Genito-Urinary
? Pain/itching of genitalia
? Genital lesions/discharge
? Painful urination
? Frequent or urgent urination
? Blood in urine
? Unable to hold urine
? Wake up to urinate
? Bedwetting
? Decreased sex drive
? Other: ______
Gastrointestinal
? Nausea and/or vomiting
? Acid reflux/heartburn
? Gas
? Bloating
? Bad breath
? Loose/soft stools
? Constipation
? Blood and/or mucus in stools
? Intestinal pain or cramping
? Itchy anus
? Burning anus
? Anal fissures
? Hemorrhoids
? Other: ______
Skin
? Hives
? Rashes
? Eczema
? Psoriasis
? Acne prone
? Dry skin
? Oily skin
? Smooth and shiny
? Bruise easily
? Other: ______
General
? Cold hands & feet
? Fever and/or chills
? Night sweats
? Spontaneous sweats
? Recent changes in weight
Fatigue
Low energy levels
1
/ Getting tired quickly
Did you have night walking as a child?
Did you have bed wetting as a child?
If you would be required to come to India for treatment, for a period of 2 – 3 weeks, will you be able to afford the time to do so? Prices for treatment vary depending on your condition.
Please choose an option of how to buy your medicines:
I would like to procure the medicines:
a)Myself
b)With the help of Purnarogya team (for details please see
ALL THE INFORMATION THAT YOU HAVE GIVEN WILL BE KEPT STRICTLY CONFIDENTIAL
DISCLAIMER
Natural healing is a gradual process which needs time and patience.
In some cases there can be some discomfort when you begin the healing process. It is due to the detoxification process and body trying to re-adjust to the normal rhythm. Please inform us of any changes by email as soon as you can.
Do not modify or stop any of your regular medications while taking the natural treatments unless advised by the doctor.
Whenever you come for a personal consultation, it is recommended to not eat anything for two hours before the consultation. Drinking water is allowed. This will help to make proper pulse diagnosis.
It is important to take responsibility to follow the advice given very strictly for optimum results.You are a very important part of the treatment. Your participation in the treatment is very important. The doctor and you will work together as a team.
Certain treatments need to be stopped during monthly cycles in case of women. Please inform us by email if your cycle begins in the middle of the treatment.
Our body is a self healing system. Each person's body is unique and the time required for healing cannot be fixed as it will vary from person to person. The time required for healing depends on many factors like body constitution, mental constitution, age, climate, food, strict adherence to life style changes, regular medication, digestive power, stage of disease, implicit faith in the process and a positive attitude.
Ayurveda is a treatment that is done step by step. Follow up consultations are essential at regular intervals to check response to treatment given and ensure proper recovery of illness and rejuvenation of the body. Follow up is essential to prevent imbalance due to overuse of the medicines as well. Medicines if used for more duration than required can potentially cause imbalance. Your physician will determine during a follow up whether it is necessary for you to continue the medicines or change to another protocol (or the next stage of treatment). It is your responsibility to ask for a follow up consultation in about one month.
Ayurvedic medicines may not be very palatable to the tongue. Please mentally prepare yourself to bear with the discomfort for the sake of your long term benefit. Thanks.
Since the physician is unable to examine the patient physicallyplease make sure to send your follow up reports regularly and pictures of tongue and any other physical lesions on the body. The follow up form give below must be filled up and sent once every week till end of treatment or until physician asks you to stop.
Follow up form:(*at least once everyweek)
(you may cut and paste these questions in your email if you prefer, and answer the questions)
Date of consultation:
Date of receiving medicines in post:
Date of starting medicines:
Please mention any changes in the following:
- Bowels/Stool: frequency / color / consistency / any other
- Bladder/Urine: frequency / color / burning sensation / any other
- Sleep pattern or quality:
- Appetite or hunger:
- Any changes in the symptoms that you had reported:
- Any part of the treatment that you were unable to implement:
- Any sudden changes in lifestyle you had to make, apart from what was recommended by the doctor, since you started the treatment
- Send an updated picture of your tongue (or other body parts where applicable)
- Send a copy of the report of any new medical investigations performed during the course of your treatment
For Official Use Only
Unique Client No.
Medical Astrology notes:
Samprapti: (Etiopathologenesis of illness):
Daçavidha/ Añöavidha parékña:
Ayurvedic diagnosis:
TCM diagnosis:
Prescription:
No. / Name of medicine / Dose / Time of administrationHome remedies:
Diet:
Exercise:
Other advice:
Date of next consultation:
Follow up notes:
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