Personal Data
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Age
Sex
Occupation
Height
Weight
Contact number
Marital Status
Single
Married
Widowed
Divorced
Emergency Contact
Relationship and Contact number
Allergies
What would you like to discuss today?
Are you currently taking any kind of medication; please list them here
Current health issues
Prior health issues
Family history of health issues
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DIGESTION
Is your digestion
Good
Fair
Poor
Is your appetite
Strong
Moderate
Mild
Variable
In general; how is your energy during the day
Strong
Medium
Low
Variable
Do you feel heavy after meals
Yes
No
Do you feel sleepy after meals
Yes
No
DO YOU HAVE ISSUES WITH: CHOOSE ALL THAT APPLY
Gas
Flatulence
Belching
Bloating
Heartburn
Acid reflux
List any foods which cause discomfort
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ELIMINATION
Do your bowel movements tend to be
Regular
Irregular
How often do you have bowel movements
Less than once every 3 days
Once daily
2-3 times every day
More than 3 times per day
Time of bowel movements
First thing in the morning
Later in the morning
In the afternoon
After dinner
Immediately after meals
Stools are usually
Soft
Medium
Hard
Variable consistency
AGNI PARIKSHA: Choose one
Mandagni K type: 1 bowel movement a day; sluggish/heavy after meals; dull appetite
Tikshnagni P type: 2-4 bowel movements a day; prone to loose stools; acid reflux/acidity; strong appetite
Vishamagni V type: 1 or less bowel movement a day; dry, hard stool; gas/flatulence; variable appetite
AMA: coating on tongue
Yes
No
Sleep
Light, irregular, difficulty in falling asleep again if woken in the night
Light but sound; falls back to sleep easily if woken in the night
Deep, heavy, not easily disturbed or woken, tendency to oversleep
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AHARA: FOOD HABITS
Breakfast choices
Lunch choices
Dinner choices
Snacks
Are you a vegetarian/vegan or non-vegetarian
do you smoke or have smoked before
Alcohol and frequency of consumption
Exercise
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