Ayurveda Treatment


It is always better to seek the advice and treatment in person from the expert Doctors as this is an ideal method of medical treatment. But if such ideal situation is not available then Internet
medical advices and treatment may be preferred, now a day such mode of treatment is common
through out the world.
Here the advised Treatment will be holistic considering System Biology approach of Ayurveda,
consisting of advices related to Diet, Herbal Supplements / Formulations and Physical and
Mental Activities > as Suitable to the disease conditions.
Prior to the treatment advices the written consent from the patient is essential, the chronic or
critical patients may send the detail reports for treatment. In general exclusively Chronic Cases
will be treated, the filling of detail information in an attached Format and attachment of all
investigations is essential to seek the proper treatment advices. The secrecy of patients will be
strictly observed and in rare cases for scientific purposes if case reporting is required in such
cases the patients personal details will not be revealed.
Mainly all chronic diseases, Metabolic and Life style related diseases will be treated, list of some
selected diseases:

Oligospermia Erectile Dysfunction Obesity Control Diabetes Control
Arthritis Osteoporosis Low Back Pain Allergy
Galactogauge (enhancing lactation) Menstrual disorders
Breast development Local
and Oral Med.
PCOD- Polycystic
Ovarian Disease
Liver disorders  Gall Stone  Renal Dysfunction  Anti-Aging
Alopecia Areata  Antidandruff  Vitiligo  Acne
Irritable Bowel Syndrome-IBS  Constipation  Urinary Calculi  Cancer Care
Post-Operative / Traumatic / Lymphatic
Obstructive and Chronic
Filarial Edema
Hypertrophied Scar
/ Keloid
 Urinary Calculi  Urethral Stricture
Macular Degeneration
 Glaucoma-Control  Dry Eye Syndrome Any Other Chr.
Disease Condition







Patient’s Information:

1. I hereby authorize the Ayurvedic Doctor to prescribe / advice the medicines to me based on my detail information provided to him. I will follow the regimen as advised, in rare if any problem occurs I will stop the Medicine and inform to the Doctor. All risk and responsibility lies on me.

Your Name (required)

Dear Patient,
The following questions are concerning to your present state of health. Please answer the all questions; this will get more time for over all assessment.

Patients Format


Sex MaleFemale





Blood Pressure

Vegetarian/non Vegetarian VegetarianNon Vegetarian

Addiction if any

Any Disease at prasent :


Contact No:

Your Email (required)


1. Do you feel efficient in your activity throughout the whole day? :

2. When do you feel at your lowest? :MorningAfter-mealsAfternoonEvening Time:

3. What is your best time of the day? : MorningAfter-mealsAfternoonEvening Time:

4. How many hours of sleep do you need?:

5. When do you wake up in the morning? :

6. What is the quality of your sleep? SoundDisturbed

7. Do you wake up refreshed in the morning? YesNo

8. How often do you eat during the day (including in-between meals)?

9. Are you really hungry (not just have an appetite) forBreakfast?Lunch?Dinner?

10. Do you feel?tiredheavy orfull (repletion) after lunch?

11. How often do you have a bowel movement?

12. Are you stools? HardSoft but formedPulpyVariable

13. Do you suffer from flatulence?

14. What taste do you prefer?
Please evaluate the following six tastes ( 1= like very much, 2= like, 3= normal,
4 = don’t like)

A. Sweet (e.g. potatoes, bread, rice, pasta, sweet fruits, sweets etc): 1= like very much,2= like,3= normal,4 = don’t like

B. Sour (yoghurt, lemon, sour fruits etc.):1= like very much,2= like,3= normal,4 = don’t like

C. Salty (Salt, Rock Salt taken extra): 1= like very much,2= like,3= normal,4 = don’t like

D. Bitter (Bitter Gourd etc.): 1= like very much,2= like,3= normal,4 = don’t like

E. Pungent (e.g. pepper, ginger, paprika etc.): 1= like very much,2= like,3= normal,4 = don’t like

F. Astringent (e.g. astringent vegetables, pulses etc.): 1= like very much,2= like,3= normal,4 = don’t like

15. Do you often have a burning sensation in the body, such As heartburnIn the intestines

16. Do you often surer: HeadacheMigraine? ?How often?

17. Do you often suffer from? ColdSore throatCoughSinusitis

18. Do you have a feeling of heaviness or pressure in ? ForeheadEyesFaceChest

19. Do you often feel a twinge or a sharp pain in the left side of the chest?

20. Do you suffer from pain? In the backIn the shoulderIn the neck

21. Do you have problems with your joints? YesNo If yes, which joints?

22. Do you have skin problems?YesNo What kind?

23. Is your skin ?RoughDryDelicateSoftSensitiveOilyWarmCold

24. Do you have experience of any method / practices for self-development? YesNo
Which method?

Question about your health in the past The following questions relate to your past diseases and present status, habits etc. Please tick the relevant diseases and indicate, as far as possible, the time of their occurrence. Current complaints, health problems

Have you ever suffered from any of the following Diseases? Yes, No and Years of Occurrence

1. Typhoid/ paratyphoid/ dysentery: YesNo, Years of Occurrence:

2. Tuberculosis : YesNo Years

3. Glaucoma: YesNo , Years of Occurrence:

4. Sinusitis: YesNo , Years of Occurrence:

5. Hyper/ hypothyroidism: YesNo , Years of Occurrence:

6. Pneumonia, pleurisy or prolonged Bronchitis: YesNo, Years of Occurrence:

7. Asthma, hay fever: YesNo , Years of Occurrence:

8. Allergic reactions, eg. Intolerance to medicaments YesNo, Years of Occurrence:

9. High blood pressure YesNo, Years of Occurrence:

10. Stroke, paralysis YesNo , Years of Occurrence:

11. Heart attack YesNo , Years of Occurrence:

12. Other cardiovascular complaints YesNo, Years of Occurrence:

13. Varicose veins, piles (hemorrhoids), thrombosis, varicose ulcer YesNo, Years of Occurrence:

14. Stomach or duodenal ulcer YesNo , Years of Occurrence:

15. Constipation, diarrhea, blood in stool YesNo , Years of Occurrence:

16. Hepatitis Liver Disease YesNo, Years of Occurrence:

17. Gall- stone YesNo , Years of Occurrence:

18. Kidney-Urinary tract diseases YesNo , Years of Occurrence:

19. Prostate disorder YesNo, Years of Occurrence:

20. Difficulties in passing urineYesNo , Years of Occurrence:

21. Need to pass urine during the night YesNo , Years of Occurrence:

22. Disorders of the breasts YesNo, Years of Occurrence:

23. Skin diseaseYesNo, what kind , :

24. Syphilis, gonorrhea YesNo , Years of Occurrence:

25. Epilepsy (convulsive disorders)YesNo, Years of Occurrence:

26. DiabetesYesNo, Years of Occurrence:

27. Gout Rheumatism ArthritisYesNo , Years of Occurrence:

28. Anemia, blood disordersYesNo; what kind?

29. Cancer (incl. cancers of the blood) YesNo , Years of Occurrence:

30. Other diseases or surgeryYesNo , Years of Occurrence:

31. Have you in the past taken medicaments? for a prolonged time?YesNo, If yes, what kind and when?:

32. Do you regularly drink alcohol ( beer, wine, strong liquor)?YesNo, If yes, how much?:

33. Do you smoke: Cigarettes,Cigars,Pipe)?How many daily?

34. Do you or did you ever take drugs (LSD, cannabis, speed, morphine, ecstasy or other? YesNo

35. Do you take proper exercise less then twice a week? Do you thing that you have not had enough success in your life: YesNo

36. Do you worry about your future?YesNo


Did any of the following disease occur in your family?
Father Mother, Children and Grand Children

High blood pressure, stroke

37. Heart attack: Father Mother,Children andGrand Children

38. Overweight Father Mother,Children andGrand Children

39. Diabetes Father Mother,Children andGrand Children

40. Gout Father Mother,Children andGrand Children

41. Nervous/emotional/mental illness Father Mother,Children andGrand Children

42. EpilepsyFather Mother,Children andGrand Children

43. Tuberculosis (TB) Father Mother,Children andGrand Children

44. Gall-kidney – or bladder stonesFather Mother,Children andGrand Children

45. Cancer (incl. blood)cancerFather Mother,Children andGrand Children

Additional questions

(Answering these is helpful but not compulsory)

46. Do you frequently feel lonely? YesNo

47. Do you have problems with your partner (spouse, girlfriend,

48. Do you have problems with your family? YesNo

49. Are you dissatisfied with your current activities (profession, household, also retirement)?YesNo

50. Are you dissatisfied with the place you live in at present (apartment, home)? YesNo

51. Are you dissatisfied with the neighbors?YesNo

52. Besides these, do you have any other Worries Problems?YesNo

53. Do you thing that you have not had enough success in your lifeYesNo

54. Do you worry about your future? YesNo


1. Age at onset of menstrual periods?

2 .Periods?(Regular/Irregular):

3. Physical symptoms preceding the periods (eg:heaviness/pain in the breasts, changes in moods, changes appetite, changes in bowel habit, backache, pain in the legs, headachs etc.) ?

4. Duration and intervals between periods (eg:bleeding last for 3-5 days and the intervals between periods is 27 days?

5. Are you using any contraceptive pills? YesNo

6. Any discharge before /during /after periods?

7. Number of children and whether the deliveries were normal? Any postdelivery problems? Were the children breastfed or not? Any problems during the breastfeeding phase? Any Abortions? Any complications after abortions?

8. Age of onset of menopause?

9. Did the periods cease gradually or abruptly?

10. Have you had any operations done in the pelvic area?