Sattvam Ayurveda

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Patient Information Form

Gender : Male Female

Would you like to be a part of Ayurveda Training Programme : Yes No

Dietary Habits

Name of the Item	Method of cooking Roast/Boil/Fry/Soak/Ferment	Ingredients
		Cereals	Pulses	Vegetable	Type of Meat	Spices	Oil/Butter/Ghee/Cheese/Yogurt
Khichadi	Boil	Rice	Moong Beans	Onion,Green Peas	None	Ginger,Turmeric,Garlic,Cinnamon,Clove	Ghee










Eating	Frequency	Schedule Breakfast/Lunch/Dinner	% Carbohydrate	% Proteins	% Fats

Behavioural Habits

Drinking	Frequency	Quantity	Nature - Cold/ Normal/Lukewarm	Relation to meals/ breakfast Before/After/in between
Water
Alcohol
Areated waters
Milk/Tea/ Coffee
Any other drink
Exercise Yes/ No: If yes answer following	Yes No

	Measure	Time in mnts	Resting period	Habit of drinking water in between
Walking	Km
Jogging	Km
Push ups	No.
Weight lifting	Kg
Yoga
Any other
Working habits	Sedentary Moving	Hrs.	Day time Night Shifts	Physical Mental Supervisory Dependent Stressful Relaxed
Sleeping habits	Regular Irregular	Night Day	Hrs.	Disturbed Undisturbed

Medical History

(Mention present complaints and treatment taken in past)

Prakruti Analysis Test

#	Characteristics	Vatta	Pitta	Kapha
1	Body Frame	Thin and Lean	Medium	Well Built
2	Type of Hair	Dry and With Split Ends	Normal, Thin, More Hair fall	Greasy, Heavy
3	Color of Hair	Pale Brown	Red or Brown	Jet Black
4	Skin	Dry, Rough	Soft, More Sweating, Acne	Moist, Greasy
5	Complexion	Dark, Blackish	Pink to Red	Glowing, White
6	Body Weight	Low, Difficult to Put on Weight	Medium, Can Easily Lose or Gain Weight	Overweight, Difficult to Lose Weight
7	Nails	Blackish, Small, Brittle	Reddish, Small	Pinkish, Big, Smooth Weight
8	Size and Color of the Teeth	Very Big or Very Small, Irregular, Blackish	Medium Sized, Yellowish	Large, Shinning White
9	Pace of Performing Work	Fast, Always in Hurry	Medium, Energetic	Slow, Steady
10	Mental Activity	Quick, Restless	Smart Intellect, Aggressive	Calm, Stable
11	Memory	Short Term Bad	Good Memory	Long Term is Best
12	Grasping Power	Grasps Quickly but not Completely and Forgets Quickly	Grasps Quickly but Completely and Have Good Memory	Grasps Late and Retains for Longer Time
13	Sleep Pattern	Interrupted, Less	Moderate	Sleepy, Lazy
14	Intolerance to Weather Conditions	Aversion to Cold	Aversion To Heat	Aversion to Moist, Rainy and Cool Weather
15	Reactions Under Adverse Situations	Anxiety, Worry, Irritability	Anger, Aggression	Calm, Reclusive, Sometimes Depressive
16	Mood	Changes Quickly have Frequent Mood Swings	Changes Slowly	Stable Constant
17	Eating Habit	Eats Quickly Without Chewing Properly	Eats at a Moderate Speed	Chews Food Properly
18	Hunger	Irregular, Any Time	Sudden Hunger Pangs, Sharp Hunger	Can Skip any Meal Easily
19	Body Temperature	Less than Normal, Hands and Feet are Cold	More than Normal, Face and Forehead Hot	Normal, Hands and Feet Slightly Cold
20	Joints	Weak, Noise on Movement	Healthy with Optimal Strength	Heavy Weight Bearing
21	Nature	Timid, Jealous	Egoistic, Fearless	Forgiving, Grateful, Not Greedy
22	Body Energy	Becomes Low in Evening, Fatigues After Less Work	Moderate, Gets Tired After Medium Work	Excellent Energy Throughout Day Not Easily Fatigued
23	Eyeball	Unsteady, Fast Moving	Moving Slowly	Steady
24	Quality of Voice	Rough with Broken Words	Fast, Commanding	Soft and Deep
25	Dreams	Sky, Wind, Flying Objects and Confusion	Fire, Light, Bright Colors, Violence	Water Pools, Gardens and Good Relationships
26	Social Relations	Makes Less Friends Prefers Solitude	Good No. of Friends	Loves to Socialize. Relationships are Long Lasting
27	Wealth	Spends without Thinking Much	Saves but Spends on Valuable Things	Prefers More Savings
28	Bowel Movements	Dry, Hard, Blackish, Scanty Stools	Soft, Yellowish, Loose Stools	Heavy, Thick, Sticky Stools
29	Walking Pace	Quick, Fast with Long Steps	Average, Steady	Slow with Short Steps
30	Communication Skills	Fast, Irrelevant Talk, Speech not Clear	Good Speaker with Genuine Argumentative Skills	Authoritative, Firm and Little Speech