Darshan Ayurveds Online Consultation Form

Daily Food Chart*

	Daily	weekly	sometime	Never
Hotelling
Chinese
Curd
Pickle
Papad
Flakes ( Poha)
Fried Food
Sprouted Food
Bakery Products
Misal / Vada-paav / Samosa / Kachori etc.
Fermented Food (Idli/ Dosa/Uttapa etc.)
Gram Food ( Besan Atta Foods)
Bhel / Panipuri / Ragada pattis etc.
Stale Food ( Baansi Cheeze)
Milk Products
Sago ( Saabudaanaa)
Fasting ( Langhan / Upvaas)
Raw Food (Uncooked Food)
Nonveg

Bowel Habbits*

	Yes	No	Sometimes
Do you visit Toilet Daily
Do you have feeling of Daefication
Do you need Tea / Coffee / other things for Sensation

Nature of Stool ( Tick which is Applicable )*

SolidSemisolidWateryStickyYellowishDark YellowishBrownishGreenishWith 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 NightSometimes during Night AlsoAlways during Night AlsoOther
Sweating / Perspiration*
About Your Sleep*

Sound sleep in NightBreaking SleepOther
Do you Have Afternoon Sleep After Lunch ?*

Stress Level*

	1	2	3	4	5	6	7	8	9	10

1 is Very Less, 10 is Too Much Stress

Gyanaecology - Fields for Female Patients Only
Your Menstrual Cycle ( In Case of Females Only)

3 Days / After 28 Daysless than 3 Days / After 28 Days4-6 Days / after 28 Days3-5 Days / After more than 30 days3-5 days / Before 28 DaysOther
Complaints During / Before / After Menstruation
Obstretic History( History Regrding Delivery)
Any History of Abortion / Misscarriage ?

YesNo
If Yes to Abortion / Misscarriage, How Many Times

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Did you Take Ayurvedic Medicines for This / Other Illness ?*

YesNo
If yes, Give Details with Medicines
Are you Ready To Follow Do's & Dont's ( Parhej / Pathya-Apathya) Strictly adviced by vaidya ?*

Yes...OfcourseNo...NeverI will Try my best
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