Patient Details Form

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SECTION 1: Personal and Contact Information

Full Name *

Age (Years) *

Phone Number *

Email Address *

Weight (kg / lbs)

Height (cm / ft-in)

Occupation

Preferred Language

SECTION 2: Health History and Current Condition

A. Chief Complaint

1. What is the main health concern or disease you wish to address? (Describe symptoms, intensity, and when it started.)

2. Has this condition been formally diagnosed? (If yes, by whom?)

B. Medical History

3. Current Modern Medicines/Prescriptions: (List all medications, dosage, and frequency.)

4. Recent Surgeries (within the last 5 years): (List the procedure and date.)

5. List any major illnesses, hospitalizations, or chronic conditions:

6. Are you currently taking any Herbal, Ayurvedic, or other Complementary Medicines? (List name and dosage.)

SECTION 3: Lifestyle, Routine, and Energy

A. Sleep Habits

1. Typical Sleep Timing (e.g., 11:00 PM to 6:00 AM):

2. Quality of Sleep: (e.g., Deep, restless, frequent waking)

3. Do you feel rested upon waking?

Yes No

B. Morning to Evening Routine

Time Slot Action / Activity

Upon Waking

7:00 AM – 9:00 AM

9:00 AM – 1:00 PM

1:00 PM – 5:00 PM

5:00 PM – 9:00 PM

9:00 PM – Bed

C. Physical Activity

4. Exercise Habit: (Type, frequency per week, and duration.)

5. Average Daily Water Intake (Liters/Glasses):

SECTION 4: Detailed Diet and Digestive Habits

1. Food Timings (Approximate time you eat):

Breakfast

Lunch (Main Meal)

Dinner

Snacks (if any)

2. Diet Type: (Tick all that apply)

Vegetarian Non-Vegetarian Vegan Eggetarian Other (Specify):

3. Describe your typical appetite (Hunger): (e.g., Strong/weak, consistent/variable)

4. Do you experience any digestive discomfort after eating? (e.g., Gas, bloating, heartburn, heaviness)

5. Bowel Movements:

Frequency (How many times per day/week?)

Consistency (e.g., Smooth, hard, loose)

SECTION 5: Previous Therapies and Goals

1. What non-diet/non-modern therapies have you tried in the past? (e.g., Panchakarma, Yoga, Acupuncture, Homeopathy)

2. What are your primary goals for this consultation? (e.g., Weight loss, better digestion, disease management, increased energy)