🌿 PCOD - Ayurvedic Patient Assessment Form

Complete assessment for personalized Ayurvedic care

Section 1 of 9 ⏱️ 3-5 minutes remaining

Please select your preferred language / कृपया आपली भाषा निवडा

🧾 Section 1: Personal Details

Full Name *

Age *

Mobile Number * Enter 10 digits only (e.g., 9876543210)

Marital Status *

Unmarried Married Trying to Conceive Postpartum

Previous Pregnancy *

Yes No

🩸 Section 2: Menstrual History

Last Menstrual Period Date *

Cycle Length *

28-32 days 33-40 days 40+ days No period for 2-3 months

Flow Type *

Light Heavy Clotting Irregular

Period Duration (days) *

Period Pain Level *

No pain Mild Moderate Severe

⚠️ Section 3: Symptoms Checklist

Please check all symptoms that apply to you

Facial acne/pimples Weight gain Hair loss/thinning Abdominal bloating/heaviness Mood swings Fatigue/weakness Anxiety/stress Sleep disturbances

🌞 Section 4: Lifestyle Assessment

Night Screen Time *

Less than 30 minutes 30-60 minutes 1-2 hours More than 2 hours

Daily Exercise/Walking *

None 2-3 days per week Daily 20-30 minutes Daily 45+ minutes

Junk/Bakery/Maida Consumption *

Rarely 1-2 times per week 3-4 times per week Daily

Water Intake Habit *

Low Moderate Adequate Warm water throughout the day

🌿 Section 5: Ayurvedic Assessment

Prakriti (Body Constitution) *

Vata Pitta Kapha Not sure

Duration of Symptoms *

Less than 3 months 3-6 months 6 months - 1 year More than 1 year

🧪 Section 6: Medical Reports (Optional)

Available Reports (Select all that apply)

Thyroid LH/FSH AMH Testosterone Fasting Insulin CBC Pelvic Sonography No reports available

Report Details/Notes (if any)

🎯 Section 7: Treatment Goals

Select your treatment goals (Choose all that apply)

Regular menstrual cycles Weight management Acne & hair fall improvement Ovulation improvement Stress & sleep improvement Prepare body for conception

📝 Section 8: Additional Notes

Your Questions/Concerns

📅 Section 9: Consultation Preference

Would you like to consult our Ayurvedic doctors? *

Please select one option below

🏥 Visit Our Clinic

Free Nadi Parikshan at our clinic locations

THANE|PUNE|DADAR|VASHI

📱 Online Consultation

Connect with our Senior Ayurvedic Doctors via WhatsApp Call or Video

Perfect if all clinic locations are far from you

₹200 (One time charges only)

✅

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