Ayurvedic Consultation

Name : Reg. No:

Age : Sex:

Chief complaints / Pradhana vedana:

Associated complaints / Anubandi vedana:

Histrory of presenting illness / Vedana vrattanta:

Histrory of past illness / Poorva vyadhi vrattanta:

Family History / Koutumbika vrattanta:

Social and occupational history / Udyoga Parisara vrattanta:

Treatment history / Poorva chikitsa vrattanta:

Psycological history / Manasika vrattanta:

Gynaecological history:

Gravida : Para : Abortion : Miscarriage :

Still birth : Number of deliveries :
Nature of delivery: Last delivery/Last child birth :

Gait:
Muscle Tone:
Co-ordination:
Atura charya

Ahara/Diet :

Agni/ Appetite :

Koshta :

Nidra :

Vyasana/Habits/ Addictions :

High risk behavior :

Ashta sthana pareeksha:

1. Nadi
Gathi :
Vega :
Tala :
Bala :
Akruthi :
Tapamana :
Kathinya :

Vikurthi :

2. Mala

3. Mootra
4. Jihva

5. Shabdha

6. Sparsha

7. Drik

8. Akriti

3. DASHAVIDHA PAREEKSHA

1. Prakruti

2. Vikruti

3. Sara

4. Samhanana

5. Pramana

6. Satmya

7. Satva

8. a) Ahara Shakti

b) Jarana shakti

9. Vyayam Shakti

10. Vaya
Samprapthi ghatakas:
Dosha
Dushya
Agni
Ama
Srotas
Srotodushti prakara
Udbhavasthana
Sanchari sthana:
Vyaktasthana:
Adhistana :
Rogamarga: