Name : Nisha J
Gender : Female
Marital Status : Married
Age : 37
Height : 5 CM
Weight - Past: 67 KG | Current: 70 KG
Occupation : Housewife
Date & Time of Birth : 03/04/1982 | 07:15 am
Place of Birth : Jalandar
Address : 346, chandigarh, UT, IN, 134116
Mobile : 985674569
EMail : nisha.icfai@rediffmail.com
Prakriti: Balanced Vata: 2 | Pitta: 2 | Kapha: 2
Level of Your Mind - Body Impurities: 29 (Moderate)
Indigestion Score: 23 (Moderate)
Parasites: 20 (Moderate)
| Question: | Response: |
|---|---|
| Please describe your present health concerns and their duration? | piles |
| How long have you had the chronic conditions about which you are consulting us? | 2 to 5 years |
| How has your health problem progressed since it began? | Fluctuating |
| 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? | About 30 minutes |
| Are you currently under the care of a family physician or any other health professional? | Yes |
| What is their opinion about your health? | Incurable |
| Have you undergone any investigations for | Urine Test, Stools Test |
| Past Prescription Medicines | ayurvedic |
| Present Prescription Medicines | homeopathy |
| Past Over the counter Medicines | piles |
| Present Over the counter Medicines | homeopathy |
| Winter | Constipation |
| Summer | |
| Spring | |
| Do you use any of the following? | microwave-cooking |
| How would you rate your usual energy level? | High |
| Describe your bowel movements? | Other |
| Please specify other bowel movements | pain and constipation |
| Bowel nature: | Hard |
| Bowel movement associated with: | Pain |
| Do you have any of the following urinary problems? | |
| Do you delay or suppress any of the following? | Bowel movements |
| Do you practice any type of meditation? Please explain. | no |
| Do you practice any Yoga techniques? Please explain. | yes |
| What is your present state of mind and emotions? | Good |
| Do you often experience any of the following? | High stress |
| Do you get up early? | Yes |
| At what time you wake up? | , 07, 00, am |
| Do you go to bed early? | Yes |
| At what time you sleep? | , 08, 00, pm |
| Do you sleep in the daytime? | Yes |
| How do you generally feel about waking up in the morning? | Little tired |
| How is your sleep? | Interrupted |
| To what direction does your head point during sleep? | East |
| What is your sleeping position? | On back |
| How regular is your daily routine (for example, do you go to bed early, eat your meals on time, exercise regularly etc?) | Very regular |
| What is your body build? | Average |
| Are you overweight? | Yes |
| If so, by how much? (In KG) | 10 |
| Do you travel a lot? | Yes |
| How often do you exercise? Please specify. | no exercise |
| How long do you exercise? | less |
| Is your exercise: (choose one) | Moderate Light |
| Do you smoke cigarettes or others? | No |
| Which type of weather makes you feel most uncomfortable? | Hot |
| Daily | Vegetables - Cooked |
| Weekly | Fruits |
| Monthly | |
| Never | |
| Do you eat between meals? | Yes |
| Do you eat your meals on time? | No |
| Which is your main meal? | Breakfast |
| Rate your digestion | Fair |
| How much water do you drink per day? | 3-4 glasses |
| My eating habits include: | Talk or converse a lot while eating |
| Describe your diet: | Vegan |
| Non-vegetarian: | |
| Have you experienced any changes in your sense of taste? (Choose one) | Bitter taste in mouth |
| What taste(s) do you like or crave? | Sweet |
| Are there any particular foods that create discomfort when you eat them? | Oily or fatty |
| How are your family relationships? | Fair |
| How is your social life? | Good |
| How is your mental status? | Good |
| How is your career? | I cannot stand it. |
| How purposeful is your life? | Somewhat |
| Rate your spiritual life: | Somewhat satisfying |
| As a child, did you experience any abuse or trauma? | Emotional, Sexual, Physical |
| Do you have any problems? | |
| Which of the following describes your menstruation? (You may choose more than one) | Regular |
| How many days does your menstrual period last? | Zero to four days |
| How is your menstrual flow? | Heavy |
| Associated symptoms (before or during menstruation): | Migraine Depression |
| Do you have any discharge outside of your menstrual period? | No |
| Do you experience pain during intercourse? | No |
| Do you have any sexual difficulties? | No |
| Are you pregnant now? | No |
| Do you take contraceptive pills or other devices? | No |
| Number of previous pregnancies (choose one) 0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 or more | 2 |
| Do you have any history of abortion, miscarriage, etc? | No |
| How many children do you have? | 2 |
| Children’s ages: | 5 |
| Do you self-exam breasts regularly? | no |
| Do you experience any problems in breasts? | Others |
| Vata Personality | I usually perform activities very quickly enthusiastically and lively by nature., I have a thin physique I dont gain weight very easily. |
| Pitta Personality | I feel uncomfortable or become easily fatigued in hot weather more than other people. , In my activities I tend to be extremely precise and orderly. |
| Kapha Personality | My body frame is heavy broad evenly proportioned., I can easily skip a meal without any difficulty. |
| Total Vata | Pitta | Kapha | My Mind-Body Personality is: VATA - {calc:vata_score} PITTA - {calc:pitta_score} KAPHA - {calc:kapha_score} |
| I generally feel constipated. | Moderate |
| I often get congestion in my head and sinuses | Moderate |
| I often get infections. | Moderate |
| I feel my immune system is weak | Moderate |
| I feel non-clarity of mind | Mild |
| I feel physically exhausted without any reason | Mild |
| I feel mentally exhausted easily | Mild |
| My stress levels are | Moderate |
| I have no desire to eat food | Severe |
| I tend to feel indigestion frequently | Moderate |
| I tend to get lot of salivation in the mouth | Moderate |
| I easily get angry and irritated without any real reason | Moderate |
| I feel that my breathing pattern altered | Mild |
| I frequently get cold throughout the year | Mild |
| I tend to get allergies throughout the year | Moderate |
| I feel heaviness in the body | Mild |
| I feel something is not well in my mind-body | Moderate |
| Body Impurities | Level of Your Mind - Body Impurities: Total: {calc:body_impurities} 1 to 17 = Mild | 17 to 34 = Moderate | 35 to 51 = Severe |
| Abdominal pain | Mild |
| Anorexia | Mild |
| Body aches | Moderate |
| Fainting | Mild |
| Fever | Mild |
| Flatulence | Mild |
| Giddiness / dizziness | Moderate |
| Gripping pain / colic | Mild |
| Headache | Moderate |
| Heaviness in abdomen | Mild |
| Improper digestion of food | Moderate |
| Malaise (Body aches) | Mild |
| Slow digestion | Moderate |
| Stiffness in back & waist | Mild |
| Thirst | Moderate |
| Vomiting | Mild |
| Yawning | Mild |
| Indigestion | Total Score: {calc:Indigestion} 1 to 13 = Mild 14 to 26 = Moderate 27 to 39 = Severe |
| Feeling tired most the time (Chronic fatigue) | Moderate |
| Digestive problems (gas, bloating, constipation or diarrhea) | Mild |
| Gastrointestinal symptoms and bulky stools with excess fat in feces | Mild |
| Food sensitivities and environmental intolerance | Moderate |
| Allergic-like reactions | Mild |
| Joint and muscle pains and inflammation | Mild |
| Anemia or iron deficiency | Moderate |
| Hives, rashes, weeping eczema, cutaneous ulcers, swelling, sores, papular lesions, itchy dermatitis | Moderate |
| Restlessness and anxiety | Mild |
| Multiple awakenings during the night and teeth grinding | Moderate |
| Excessive amounts of bacterial or viral infections | Mild |
| Depression | Moderate |
| Difficulty gaining or losing weight | Moderate |