Swasthya Clinic – Pune, India Page 1

Ayurvedic Health Questionnaire

Please read the following questions carefully and answer them.

If you cannot answer certain questions, leave them aside.
If you want to add any other information, please do not hesitate to do it.

A. General data
Name: Jayashree Occupation: Housewife
Place of birth: Sankeshwar
Age: 63 Gender:Female
Marital status: Married Number of children: 3
Weight: 97kgs Height: 5ft
Blood pressure: High (180/90)
Address: Bangalore
Email id: somanathgm12@[Link]

B. History of the recent illness

Complaint no.1

1. What is the nature of the complaint? -

BP/ Sugar patient with the following symptoms
a) Weakness in limbs and hands ( shivering compliant)
b) Executing sudden / unplanned house hold work can lead to tension
c) Undecisive at all times
d) Palpitations / heavy breathing when walking
e) Swelling in legs
f) Drowsy/ weakness after having breakfast / meals
g) Constipation
h) Reduced eyesight / trouble reading
i) forgetfulness

2. When did it start?

High BP / Sugar was detected in 2004 (symptoms were there since 2001)

3. How did it start? Did any particular incident happen at that time?
Household issues ( husbands financial status / debts during late 90’s )

4. What is its intensity and frequency?

Currently on the medicines
a) Insulin (30 – 0 – 28)
b) Nebicard 5mg (1-0-1)
c) Nitirofix SR 30 mg (1-0-0)
d) Deplat A 150 mg ( 0-1-0)
e) Atorva 40 mg ( 0-0-1)
f) Envas 5 mg ( 1-0-0)
Swasthya Clinic – Pune, India Page 2

5. Are there any aggravating and/or reducing factors?

a) Too much standing for an hour while cooking
b) When trying to walk
c) Sleeping / Resting will make me relaxed
d) When arguing – usually tend to get tensed or uneasy which may lead to
crying or high BP

6. At what time of the day does it get worse or better?

a) When working ( cooking food ) or some small house work in standing
position worsens the situation
b) Don’t feel relaxed after waling up in the evening

7. Any seasonal variation?

a) Summer is very bad – leads to sweating , heat pricks , weakness

b) Body pain in winter

8. Any relationship with diet and life style?

a) Likes eating salty and spicy food

Complaint no.2 – Same data as above.

Complaint no.3 – Same data as above, and so on.

C. Past history of the illness.

1. Any disease in the past and its history as above

2. Medication / treatment taken or followed in the past

In 2015 – creatinine levels shot up, potassium dropped, sodium increased. She
was hospitalized in ICU and then in ICU – due to nerve compression, she had a
heart attack (resolved thru a stunt)

D. Laboratory reports.
Blood test, X-ray, sonography/echography, scan reports, reports of any other
tests done for the recent illness.
.

E. Information about the daily routine and life style

Swasthya Clinic – Pune, India Page 3

1 At what time do you wake up?

7 AM

2 Do you feel fresh or tired after waking up?

Sometimes fresh

3 At what time do you go to bed?

11 PM

4 How is your sleep: sound, disturbed, etc.?

Sound ( sometimes when tensed / wake up for urine )

5 How many times you go for motions in a day

Once in the day in the morning ( sometimes in once in 2 days )

9. How is the consistency of the motions normally?

a. Well formed like a banana ( Yes )
b. Hard and dry ( sometimes )
c. Semi solid.
d. Sticky, sticks to the pot.
e. Loose.
f. Any other form.

12. What is the colour of the stool: light yellow / dark yellow / whitish /
blackish / any other? – ( yellow )

13. What do you have in the morning before breakfast: tea / coffee / milk /
juice / warm or cold water? How much?
½ Glass water – 7 AM
Glass tea – 7:30 AM with biscuits
Breakfast - 10 am to 11 AM

14. Do you exercise in the morning? What type of exercise? How long? How do
you feel after that – fresh and light / energetic / tired / exhausted, etc?

None

Any exercise in the evening and its information as above.

None

15. Do you prefer hot/cold water for the bath? Do you bathe before or after
breakfast?
After breakfast ( after 1 hour with hot water )
Swasthya Clinic – Pune, India Page 4

16. Describe your daily diet in detail.

- What do you have for breakfast, lunch, dinner and in between, in
general?
Breakfast – Poha, Uppit, Chapati, Roti
Lunch – Chapati / Roti with rice (sambar, curds, milk , chutney)
Dinner - Chapati / Roti with rice (sambar, curds, milk , chutney)

- What is the quantity? ( 1 chapati , 1 bowl rice, vegetables/ sambar/

curds)
- Do you feel hunger every time before having food or you just eat on
time without waiting for the hunger? ( usually feel hungry )
- Which type of food do you prefer? Which taste do you prefer: sweet,
sour, salty, bitter, pungent and astringent? (salty / pungent , like ghee)
- What you do not like or what do you deliberately avoid and why?
Does not like Sour foods ( like the sourness in Dosa)

- How you feel after eating: energetic / lethargic / heavy overfull /

satisfied / unsatisfied / any other feeling?

lethargic / heavy overfull / weakness in limbs

- When do you get the next hunger, especially after your biggest meal
(breakfast/lunch)?

Usually breakfast is heavy , gets hungry after 4 to 5 hours

- What do you prefer, cold or warm food? – hot boiling food

- Have you changed your diet recently, and why? Trying to avoid salty/
pungent food. Stopped sweet

- How much oil/butter/ghee (Indian clarified butter), cheese, do you have

in your daily food? - usually we use more oil

- Which type of oil do you use for cooking? - filtered ground nut oil last 2
years

17. How much water do you drink? Do you drink water even if you do not feel
thirsty? Do you prefer warm/cold /normal water? What other liquid/s do you
have besides water, and how much?
- Drinks when thirsty / doctors have advised less water
- Likes cold water
- Drinks warm water after meals
- Butter mill sometimes
Swasthya Clinic – Pune, India Page 5

18. How many times do you urinate? What is the colour of the urine? Does the
urine have any strong or unpleasant smell?
- 6 to 7 times day time
- 1 or 2 times during night

19. How much do you sweat (as compared to others, less or more)? Does your
sweat have any strong or unpleasant smell?
- Usually sweat more in summer

20. Describe your daily working pattern.

- What type of work do you do? What are your working hours? How much
exertion do you have on the work, or is it a sedentary work? How much
do you travel in a day, and how?

- Is your working place centrally air conditioned? Do you like cold / warm
temperature? Have you had any recent change in your work pattern?

- Do you have shifts in your work, e.g. morning duty, night duty?

21. What hobby or pastime do you have?

22. Do you have any addiction? If so, describe it/them: type, frequency,
quantity, etc.

23. Any other information about your life style?

F. Information about your mental health.

1. Any mental health problems?

2. Describe your family and your interpersonal relationships.

- Feels neglected in the family / daughter in law isuues
- Not happy with the past

G. Please examine yourself and answer the following questions.

1. How is your tongue looking: clear/ coated / heavily coated?
- Clear with some white coating in the back

2. Do you have tendency to mouth ulcers? - No

Swasthya Clinic – Pune, India Page 6

3. How is the health of your hair? Do you get dandruff? Is there any hair
whitening and/or falling? – Healthy hair
.

4. Any special information about the eyes / nose / throat / ears?

Low eyesight .

5. How is the functioning of the brain - memory/intellect?

Forgets the current task being executed / low memory where
items are kept

6. How is your skin: oily / dry / wrinkled? Does it get tanned easily? Do you
have any skin problem?
Oily skin

7. How is your body temperature in general?

Cold

8. Is there excessive heat on the head, eyes, palms and/or soles? – None

9. How is your stomach? Is there any bloating / extra fat / pain, etc.? – 97 Kgs
weight / 5 feet. Usually bloated

H. Do you have any associated complaints?

If yes, give their details as asked in part B.

Example: Acidity (burning in the chest and stomach), headache, tingling and
numbness, pain, arthritis, body ache, impaired hearing/vision, tasteless mouth,
lethargy, insomnia, restlessness, muscle cramps, stiffness, sound in the joints,
constipation, gas, burps, nausea, vomiting, cracks on the soles, burning
micturition (urination), allergies, or any other complaint.

I. Give details about your gynaecology and obstetrics history.

Do you suffer from any abdominal pain? What is the colour of the menstrual
blood: red / light red / blackish? Do you have any complaints as clotting,
excessive bleeding, irregularity, etc? Any discharge? Do you suffer from breast
inflammation or pain?

Do you suffer from premenstrual troubles? If so, describe them.

Have you had any pregnancy? If so, how many deliveries? Did you have any
problems during pregnancy (s) or delivery (s)? Have you had any miscarriage?
Swasthya Clinic – Pune, India Page 7

When was your last period? If it applies, how have you experienced your
menopause?