Consult

Consult

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Patient's Basic Info

Patient First Name (Given Name)*

First Name

Patient Last Name (Surname)

Last Name

Email Address*

Email Address

Mobile Number*

mobile no.

Address*

House No, Street and Landmark

City

Country

Province or State

Postal Code

Date of Birth*

DD/MM/Year format

Date of Birth

Sex*

gender

Male

Female

Height*

In Feet and Inches or in centimeter (cm).

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Body Weight (in Kg)*

write your body weight in Kilograms

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Occupation

What are you doing

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Alcohol, Substance Use & Drug Addiction

Provide details: What do you take? How much do you take? When do you take it? How often do you take?

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Medical History: Health Conditions

Main Problem & History of Present Illness*

Explain Your Primary Complaint Including Symptoms, Duration & Progression. You must include your symptoms and what do you feel.

Main Problem

Secondary Problems

Describe Secondary Problems & other Associated Diseases for that you are taking treatment.

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Test & Investigations Reports

Write conclusions of reports (Email Reports at healing@ayurtimes.org)

Write conclusions

Treatment History

Write history of treatment taken for the present illness and what were its outcome:

Explain here

Medications, Herbs & Supplements

Provide details of medicines, herbs and supplements (along with dosage) that you are currently taking for any health condition.

Explain here

History of Past Illness

Explain Your Past Illness, Duration, and Treatment

Explain here

Family History

Write details of illnesses running in your family members (parents, brothers, sisters, paternal or maternal uncles etc.)

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Menstrual History (Important)

Nature of periods

Tick things that applicable to you

Regular Periods

Irregular Periods

Absent Period

Pain before periods

Pain during periods

Pain after periods

Scanty Period

Heavy Bleeding during Periods

Clots in the menstrual blood

Prolong Period (more than 7 days)

Short Period (less than 2 days)

No Periods because I am Pregnant

No Periods because of breastfeeding

No Periods because of surgery

No Periods because of medication or contraceptives

Menopause

If no periods because of surgery, please explain nature of surgery

Only uterus removed

Uterus and both ovaries removed

Uterus and only one ovary removed

Only one ovary removed

Both ovaries removed

Don't Know

Menstrual Periods have stopped

Select the age (in years) at which your menstrual periods have stopped

Younger than 20

20 - 29

30 - 39

40 - 44

45 - 49

50 - 54

55 - 59

60 or older

Length of bleeding (days)

How many days does your menstrual cycle last?

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Interval between the menstrual cycles

Write average gap between the periods (in days)

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Menopause

If menopause, write your age at which you first experienced symptoms of menopause?

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History of Contraception

Explain in detail history of contraception

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Ayurvedic Analysis

Appetite

Good Appetite (Normal)

Complete Loss of Appetite

Weak appetite – does not feel much appetite & can skip a meal

Sharp Appetite – Cannot skip a meal

Irregular - Sometimes feel good appetite and sometimes weak, sometimes you can skip a meal, but sometimes you cannot skip a meal

Digestion

Select appropriate

Very Weak - I cannot digest food and feel discomfort in abdomen after eating.

Weak - I can digest some of foods, but I still feel my digestion is weak.

Good - I can digest almost every healthy food.

Great - I can digest everything that comes in my plate.

Nature of Thirst

Select appropriate

Normal – No significant problem

I don’t feel thirst

I feel excessive thirst

Salivation

Saliva Production

Normal – No significant problem

Dryness of mouth

Excessive Salivation

Taste of Mouth

Normal & Abnormal Tastes

Normal

Sweet

Sour

Salty

Bitter

Pungent

Astringent

Loss of taste sensation

Something abnormal, but unable to define

Tongue Appearance

Check it in the morning before brushing

Normal

Cracked Tongue

Red, Mouth Ulcer

White Coated

Yellow Coated

Black Coated

Red Spots

White Spots

Ulcerated Tongue

Inflamed Tongue

Abdominal Comfort after eating

Feel satiety and no discomfort

I still have food craving after eating healthy foods.

I feel abdominal heaviness.

I have bowel movement immediately after eating food.

I have burning sensation after eating.

I have pain in abdomen after eating.

Acidity

Tick that applicable to you

Normal - No Problem

Heartburn

Burning Sensation in the Abdomen

Acid Reflex (Acids Coming Up Into Your Mouth Or Throat)

Belching

If you have belching, select characteristics

No problem

Belching after food

Sour belching

Astringent belching

Bitter belching

Belching with taste of food eaten.

Gas & Flatulence

No problem

Seldom

Frequent

After Certain Foods

More than 20 times a day

Frequency of Bowel Movement

1 to 2 Times Per day

2 to 3 Times Per day

More Than 3 Times Per day

Alternative Day

Less than 3 Bowel Movements per Week

Bowel Habits

Normal

I forcibly obstruct or suppress bowel movement

I use laxative for having bowel movement

Constipation (sometimes, I feel constipated)

Chronic Constipation (suffering from constipation for several weeks)

I feel my bowel is not clearing properly

Stool Characteristics

Normal - No Problem

Loose Stools

Hard Stool

Sticky, Oily, Hard to Flush

Foul Smelling

Separate hard lumps

Passing stool with Burning Sensation

Feeling Burning sensation in anal region after bowel movement

Passing stool with expulsion of Gas

Have pain while passing stool

Bloating

Normal - No Problem

Seldom

Several Times a Month

Several Times a Week

Daily

I always feel bloated.

Abdominal Tenderness

When the abdomen is palpated with hands, you feel pain. Palpate various parts of your abdomen and check if you have any pain in any part of the abdomen.

No Problem

Epigastric (upper central region of the abdomen)

I have tenderness in lower abdomen

Navel (central region of the abdomen)

Lower abdomen

Abdominal Pain

Normal - No Problem

Mild Abdominal Pain

Moderate Abdominal Pain

Severe Abdominal Pain

Irregular Abdominal Cramps

Characteristics of Abdominal Pain

If you have abdominal pain, select the characteristics and location of pain

Colicky Pain

Pain releived by bowel movement

Pain accompanied by bloating

Pain on empty stomach

Pain immediately after eating

Epigastric (upper central region of the abdomen)

Navel (central region of the abdomen)

Pain accompanied by nausea

Pulse Rate

Write your pulse rate per minute

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Blood Pressure

Write last measured blood pressure (mmHg)

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Breathing

Normal Breathing

Difficult or laboured breathing

Severe shortness of breath and coughing at night (Paroxysmal Nocturnal Dyspnoea)

Shortness of breath when lying flat (Orthopnoea)

Heartbeat

What do you feel regarding your heartbeat

Normal

Rapid heartbeat (palpitation)

Slow heartbeat

Feeling and Sensation

How do you feel?

Normal

Restlessness

Dizziness

Tired

Swelling

No Swelling

Swelling on Joints

Swelling of Feet

Facial swelling

Swelling of other parts of body

Cough, Wheezing or Asthma

Do you have cough, wheezing or asthma?

Yes

Characteristics of Cough

Select Characteristics of Cough applicable to you

Present less than 3 weeks (Acute Cough)

Present more than 3 weeks but less than 8 weeks (Subacute Cough)

Present more than 8 weeks (Chronic Cough)

Dry Cough (No Mucus)

Persistent Cough Attack

Pain in chest while coughing

Cough starts with itching or irritation in the throat

Cough accompanying by throat pain

Difficult to eat because of excessive and persistant cough

Cough with Fever

Cough with wheezing

Productive Cough (Molderate Mucus)

Productive Cough (Large Mucus)

Cough with strider

Cough worse in mornings

Cough worse at nights

Cough with bloody mucus

Cough is causing distress

Characteristics of Expectoration

Describe Sputum and its characteristics

Sputum or mucus is thin

Minimal Mucus

Gray of black mucus

Yellow or greenish color mucus

Large amount of mucus production

Cloudy mucus

White thin mucus

White mucus with lumps

Sticky mucus

Blood in sputum

Skin Type

Dry & Rough

Soft, Delicate & Slightly oily

Softer, Plump, Delicate, Pleasing & Oily or greasy

Sweating

Less sweating

Excessive sweating

Normal to Moderate sweating

Hairs

Dry, rough, thin, smoky, cracked hairs

Soft, thin hairs or early graying, baldness

Dark, Strong, thick hairs

Ease of gaining or losing weight

Difficult to gain weight

Can gain weight as well as can lose weight easily

Easy to gain weight, but very difficult to reduce it back

Sleep

Normal

Disturbed Sleep

Irregular Sleep Pattern

Insomnia (Sleeplessness)

Excessive Sleep

Dreams

Characteristics of Dreams

Normal Dreams

Disturbing

Nightmares

I see myself fearful and anxious in dreams.

Dreams of something or yourself as moving, flying, climbing, wandering, riding

Hearing rumbling voices

Dreams are of adventures, conflicts

Dreams are of fire, lightening, flash, sun, burning substances, flames, falling meteors

See red color in dreams

See clouds, water, blooming flowers in dreams

See swimming in water

Seeing sprinkle of rain

Attentiveness

Less attentive

Attentive to only one subject

Simultaneously attentive on every point

Memory

Weak

Moderately Good

Good Memory

Grasping Power

Quick, but forget easily

Good

Grasping take time, but remember longer

Ease of Decision Making

Indecisive and confused

Can make own decisions and create goals

Follows others and take advice from many people, then make a final decision

Mental Well-being

Do you have any of these symptoms? If yes, please tick the boxes applicable to you.

Agitation - state of extreme emotional disturbance

Get frequently angry - but for a short period

Rage - Extreme Angry outbursts

Becomes irritable even for small matters

Frustration - upset or annoying feeling because of inability to achieve something.

Restlessness - feeling of uneasiness

Palpitations

Aggressive behavior - causing verbal abuse to others

Aggressive behavior - causing physical abuse to others

Cannot endure noise

Fear with sweating

Suicidal thoughts

Feeling heat in head

Feeling burning sensation in head

Anxiety - a feeling of nervousness

Depression - feeling of disheartenedness and hopelessness

Irritability

Lethargic - feeling sluggishness

Melancholy - feeling of thoughtful sadness

Overwhelm - filled with uncontrollable emotion

Resentment - bitter indignation

Worry

Self Blaming

Self-destructiveness

Other Details

Please write here if you want to share anything particular that you feel or experience.

Write Here

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