| Current Date: |
|
| Patient Name: |
|
| Whether your skin remains oily throughout the year in comparison to others? |
Yes
No
|
| Are your body-hairs & skin shiny, even when no oil or moisturizer is used? |
Yes No
|
| Are you considered attractive among your friends? |
Yes No
|
| Do even mild or trivial injuries on your body make you upset? |
Yes No
|
| Among your family members, is your complexion considered fairer? |
Yes No
|
| Have you got well built muscles? |
Yes No
|
| Do you change your body posture frequently? (You cannot manage yourself in a stable posture for a long
duration.) |
Yes No
|
| Do you have a well-nourished & normally developed body? (You are neither malnourished
nor obese.) |
Yes No
|
| Are you lazy and disinterested in activities like morning walk/ jogging, swimming or any type of outdoor games? |
Yes No
|
| Are you slow in consuming the food?(Even after all have left the dining hall, you are still
consuming the same amount of food). |
Yes No
|
| When you go to morning walk or college or office, do you walk slowly in comparison to others? |
Yes No
|
| If you are assigned any work, do you take some extra time to start it? |
Yes No
|
| Do you get irritated easily? (For example, when you don’t get breakfast on time in your hostel or when the power goes off while watching a cricket match or your
favourite movie on television). |
Yes No
|
| Are you late to develop/suffer from symptoms after exposure to common causative factors? (For example,during seasonal changes, when your friends are easily caught up with flu etc., you are still healthy among them). |
Yes No
|
| Does your gait (style of walking) change with respect to speed or manner frequently? |
Yes No
|
| Do you feel hungry more frequently and do you consume more food in comparison to others? |
Yes No
|
| Do you tolerate heat easily? |
Yes No
|
| Do you consume liquids in more quantity and frequency in comparison to others?
|
Yes No
|
| Do you perspire less in comparison to others?
|
Yes No
|
| Are sounds produced frequently in your joints on movement?
|
Yes No
|
| Have you got a good/ attractive complexion?
|
Yes No
|
| Have you got sweet & pleasant voice? |
Yes
No
|
| Are you more comfortable in winter than summer? |
Yes
No
|
| Among your family members, is your complexion considered fairer? |
Yes
No
|
| Does your temperature of oral cavity remain towards upper limit of normal range? |
Yes
No
|
| Do you have excessive black moles, Freckles etc on your skin? Or Have you noticed new appearance of black moles often on your skin? |
Yes
No
|
| Have you experienced premature graying, wrinkling of skin & early baldness? |
Yes
No
|
| Do you have soft, scanty, brown hair on your face, body & head? |
Yes
No
|
| Do you involve yourself in risky & heroic activities requiring physical strength often? |
Yes
No
|
| Do you have ability to digest large quantities of food easily? |
Yes
No
|
| Do you take large quantities of food & drink in comparison to others? |
Yes
No
|
| Do you get easily irritated for small/negligible problem in day-to-day life? |
Yes
No
|
| Do you consume food more frequently than others? (5-6 times/day) |
Yes
No
|
| Do you have soft & loose muscle bulk especially around the joints? |
Yes
No
|
| In comparison to others do you pass urine & stool in large quantities and do you perspire more? |
Yes
No
|
| Do your friends complain of bad smell being emitted from your body & mouth? |
Yes
No
|
| Do you feel excessive hunger & thirst in comparison to others? |
Yes
No
|
| Whether your skin remains dry throughout the year in comparison to others? |
Yes
No
|
| Is your body undernourished/ emaciated? |
Yes
No
|
| Have you got rough, low, broken or obstructed voice? |
Yes
No
|
| Does Your sleep last less than 6 hours per day? Or Can your sleep be disturbed easily? |
Yes
No
|
| Do you change walking speed & style from time to time? |
Yes
No
|
| Do you keep changing your food habits from time to time? |
Yes
No
|
| Do you keep changing your walking / jogging habit from time to time? |
Yes
No
|
| Have you observed any additional sound in comparison to others at the time of joint movements? |
Yes
No
|
| Do you get attracted to cold & eat hot food & hot environment, do you frequently have a desire to take bath in hot water? OR Are you more attracted towards cold, consuming cold & oily food, do you desire to take bath in cold water? |
Yes
No
|
| Do you use to eat snacks / fruits like oranges, apples, grapes etc., between meals? Do you desire to eat mango, banana, papaya, lychee, jackfruit, custard apple etc. in large quantity in summer? OR Do you have no desire for snacks / fruits like oranges, apples, grapes etc., between meals? Are you in the habit of eating these fruits in small quantity? Do you desire to eat dry fruits like cashew, almond, walnut, pista etc. in winter? |
Yes
No
|
| Are you indifferent towards milk, meat, milk products etc. in comparison to others? |
Yes
No
|
| Are you in habit of avoiding milk, meat, milk products, non-vegetarian diet, brinjal, spicy food etc. more often? |
Yes
No
|
| Do you have an aversion to spinach, fenugreek, radish, onion, garlic, ginger, turmeric, mustard seeds, tomato etc.? |
Yes
No
|
| Do you use to drink excessive water or your consumption of water is less than normal? |
Yes
No
|
| Have you faced the problem of decreased fertility, do you take a long time to conceive, do you undergo repeated abortions? |
Yes
No
|
| Do you get dream during sleep often? OR Do you often see the dream of falling in a hole, often see the dream of flying in the sky, often see the dream of swimming in the water, often see the dream of being injured etc.? |
Yes
No
|
| Do you often change your way of walking? |
Yes
No
|
| Do you change the way you wear clothes / comb your hair? Or Do you change the way you take bath & clean your teeth? |
Yes
No
|
| Do you start any new work with great enthusiasm, but later become indifferent to it? |
Yes
No
|
| Do you get angry more often or lose patience? |
Yes
No
|
| Do you have a habit of learning and forgetting it easily? |
Yes
No
|
| Do you have a habit of saving money? |
Yes
No
|
| Do you often make plans but rarely complete them? |
Yes
No
|
| Do you have any complaints of backache, weakness, pain in joints etc. in comparison to others? |
Yes
No
|
| Do you get constipation often, or get stomachache, indigestion, headache, joint pain etc. after consuming food? |
Yes
No
|
| Are you used to take in use of tobacco & other types of intoxicants more often? |
Yes
No
|
| Are you able to work without eating and drinking for 1 day? |
Yes
No
|
| Do you use to watch TV / listen to radio or are you in the habit of using mobile for a long time? |
Yes
No
|
| Do you become very happy, laugh loudly, have a desire to dance / sing & talk when you get good news etc. and get sad, cry, feel lonely, do not talk to anyone when you get bad news? |
Yes
No
|
| Do you get scared easily & try to hide in the lap of your mother, father or someone else? |
Yes
No
|
| Have you ever been diagnosed with any severe disease, or do you have any severe disease in comparison to others? |
Yes
No
|
| Do you remember & talk about the events of the past often? |
Yes
No
|
| Do you have a habit of excessive attachment to anyone or something, and you don’t have attachment for anyone or anything? |
Yes
No
|
| Have you faced the problem of sleeplessness in the night? |
Yes
No
|
| Do you have the habit of thinking & making plans & arrangements for the future, or you are careless for the future? |
Yes
No
|
| Do you have complaints of pain, headache, perspiration, loose motions, feeling of weakness & lethargy in hot weather or get complaints of skin allergies etc.? |
Yes
No
|
