Name : Deepak Sharma
Gender : Male
Marital Status : Single
Age : 26
Height : 178 CM
Weight - Past: 68 KG | Current: 70 KG
Occupation : Programmer
Date & Time of Birth : 23/07/1997 | 12:00 am
Place of Birth : Chandigarh
Address : 123`, Chandigarh, Chandigarh, IN, 160102
Mobile : 1234567897
EMail : ram@gmail.com
Prakriti: Balanced Vata: 0 | Pitta: 0 | Kapha: 0
Level of Your Mind - Body Impurities: 0 (Mild)
Indigestion Score: 0 (Mild)
Parasites: 0 (Mild)
| Question: | Response: |
|---|---|
| Please describe your present health concerns and their duration? | Lorem ipsum dolor sit amet |
| How long have you had the chronic conditions about which you are consulting us? | 6 months to 2 years |
| How has your health problem progressed since it began? | Gradually improving |
| Please explain the overall intensity of your symptoms? | Severe |
| Is your sleep disturbed by the symptoms? | Not at all |
| How often are you having pain or discomfort? | Less than once a week |
| How long does the pain or discomfort last on the average? | No pain |
| Are you currently under the care of a family physician or any other health professional? | Yes |
| If yes, please mention | Lorem ipsum dolor sit amet |
| What is their opinion about your health? | Difficult to cure |
| Have you undergone any investigations for | X-ray, Blood Test |
| Other Tests: | Lorem ipsum dolor sit amet |
| Past Prescription Medicines | Lorem ipsum dolor sit amet |
| Present Prescription Medicines | Lorem ipsum dolor sit amet |
| Past Over the counter Medicines | Lorem ipsum dolor sit amet |
| Present Over the counter Medicines | Lorem ipsum dolor sit amet |
| Past Herbs / Vitamins | Lorem ipsum dolor sit amet |
| Present Herbs / Vitamins | Lorem ipsum dolor sit amet |
| Winter | Attention Deficit, Stomachaches, Dry rough skin, Hyperactivity |
| Summer | Excessive competition, Excessive body heat, Burning in the eyes |
| Spring | Difficulty paying attention, Spaceyness distracted, Slow digestion, Neediness |
| Are you allergic to any substances? Please specify: food, pollen, dust etc., and any other allergic reactions? | Lorem ipsum dolor sit amet |
| Health as a child: | Good |
| Any Childhood Illness? Please specify. | Lorem ipsum dolor sit amet |
| Did you had any Immunizations / Vaccinations:? Please specify. | Lorem ipsum dolor sit amet |
| Any Vaccination Reaction: | Lorem ipsum dolor sit amet |
| Do you use any of the following? | aluminum-cookware, microwave-cooking |
| How would you rate your usual energy level? | Moderate |
| Describe your bowel movements? | Once every 2-3 days, First thing in the morning, Immediately after meals |
| Please specify other bowel movements | Lorem ipsum dolor sit amet |
| Bowel nature: | Soft |
| Bowel movement associated with: | Blood |
| Specify if other bowel movement association | Lorem ipsum dolor sit amet |
| Do you have any of the following urinary problems? | Urination several times during the night, Urine retention, Burning sensation |
| Specify other urinary problems, if any | Lorem ipsum dolor sit amet |
| Do you delay or suppress any of the following? | Sleep, Thirst, Tears, Burping |
| Do you practice any type of meditation? Please explain. | Lorem ipsum dolor sit amet |
| Do you practice any Yoga techniques? Please explain. | Lorem ipsum dolor sit amet |
| What is your present state of mind and emotions? | Good |
| Do you often experience any of the following? | Lack of energy, Anger, Anxiety, Light-headedness |
| Do you get up early? | Yes |
| At what time you wake up? | , 12, 00, am |
| Do you go to bed early? | Yes |
| At what time you sleep? | , 12, 00, am |
| Do you sleep in the daytime? | Yes |
| How do you generally feel about waking up in the morning? | Little tired |
| How is your sleep? | Normal duration |
| To what direction does your head point during sleep? | East, West, Northeast |
| What is your sleeping position? | On back, Left side |
| How regular is your daily routine (for example, do you go to bed early, eat your meals on time, exercise regularly etc?) | Somewhat regular |
| What is your body build? | Average |
| Are you overweight? | No |
| If so, by how much? (In KG) | 55 |
| Do you travel a lot? | Yes |
| How often do you exercise? Please specify. | Lorem ipsum dolor sit amet |
| How long do you exercise? | Lorem ipsum dolor sit amet |
| What type of exercise? | Lorem ipsum dolor sit amet |
| Is your exercise: (choose one) | Vigorous |
| Do you smoke cigarettes or others? | Yes |
| If yes, how many per day? | Lorem ipsum dolor sit amet |
| How often do you drink alcohol & How Much? | Lorem ipsum dolor sit amet |
| How often do you drink coffee, tea etc? | Lorem ipsum dolor sit amet |
| Which type of weather makes you feel most uncomfortable? | Hot |
| Daily | Vegetables - Cooked, Seafood |
| Weekly | Poultry, Vegetables - Raw Salad, Vegetables - Cooked |
| Monthly | Fruits, Sugar Honey, Juices |
| Never | Poultry |
| Breakfast: | Lorem ipsum dolor sit amet |
| Lunch | Lorem ipsum dolor sit amet |
| Dinner | Lorem ipsum dolor sit amet |
| Snacks | Lorem ipsum dolor sit amet |
| Do you eat between meals? | Yes |
| Do you eat your meals on time? | No |
| Which is your main meal? | Lunch |
| My eating habits include: | |
| Describe your diet: | Lacto-vegetarian |
| Specify other diet, if any. | Lorem ipsum dolor sit amet |
| Non-vegetarian: | |
| Specify Other Non-vegetarian diet, if any. | Lorem ipsum dolor sit amet |
| What taste(s) do you like or crave? | HotSpicy |
| Are there any particular foods that create discomfort when you eat them? | |
| As a child, did you experience any abuse or trauma? | |
| Do you have any problems? | |
| Which of the following describes your menstruation? (You may choose more than one) | |
| How many days does your menstrual period last? | |
| Associated symptoms (before or during menstruation): | |
| Do you experience any problems in breasts? | |
| Vata Personality | |
| Pitta Personality | |
| Kapha Personality | |
| Total Vata | Pitta | Kapha | My Mind-Body Personality is: VATA - {calc:vata_score} PITTA - {calc:pitta_score} KAPHA - {calc:kapha_score} |
| Body Impurities | Level of Your Mind - Body Impurities: Total: {calc:body_impurities} 1 to 17 = Mild | 17 to 34 = Moderate | 35 to 51 = Severe |
| Indigestion | Total Score: {calc:Indigestion} 1 to 13 = Mild 14 to 26 = Moderate 27 to 39 = Severe |