About this template
An Ayurvedic Case Diagnosis Form is an essential intake questionnaire used by practitioners of Ayurvedic medicine to gather comprehensive patient history, lifestyle patterns, and clinical symptoms. Proper Ayurvedic diagnosis relies heavily on understanding an individual's unique constitution, daily routines, dietary habits, and environmental triggers.
This template streamlines the initial consultation process by capturing key patient metrics—from basic demographic data and vital signs to detailed daily food charts, bowel habits, sleep quality, and stress levels. It also tracks specific Ayurvedic diagnostic elements such as main complaints, symptom triggers, previous illness history, and herbal medicine use.
Designed for holistic health practitioners, wellness clinics, and Ayurvedic doctors, this template helps you collect structured patient data prior to consultations. By using Doc2Form, you can instantly turn this comprehensive intake questionnaire into a ready-to-use Google Form, ensuring a smooth digital onboarding experience for your patients while organizing clinical notes efficiently.
Key features
- Capture complete patient demographic and vital information instantly.
- Record detailed daily routines, sleep patterns, and dietary habits.
- Document Ayurvedic-specific health indicators like digestion and bowel movements.
- Track previous medical, surgical, and family illness histories seamlessly.
- Collect patient medical reports and scanned documents via file upload links.
Use cases
Initial holistic health consultations at an Ayurvedic wellness clinic.
Remote patient intake for virtual herbal medicine and lifestyle coach…
Remote patient intake for virtual herbal medicine and lifestyle coaching.
Comprehensive case-taking for student practitioners and clinical rese…
Comprehensive case-taking for student practitioners and clinical research.
What this form collects
- Full Name (Short answer)Enter your first and last name as it appears on official documents.
- Birth Date (Date)Select your date of birth.
- Gender (Multiple choice)Select your gender identity.
- Address (Paragraph)Provide your current residential address.
- Mobile Number (Short answer)Enter your primary phone number for appointment reminders.
- Email Address (Short answer)Enter your email address to receive consultation follow-ups.
- Occupation (Short answer)What is your current line of work?
- Weight (kg) (Short answer)Enter your current weight in kilograms.
- Main Complaints (Paragraph)Describe your primary health concerns and how long you have experienced them.
- Symptom Triggers & Relief Factors (Paragraph)What makes your symptoms better or worse (e.g., weather, time of day, certain foods)?
- Previous Illness History (Paragraph)List any major past illnesses, chronic conditions, or hospitalizations.
- Surgical History Status (Multiple choice)Have you undergone any surgeries in the past?
- Surgical History Details (Paragraph)If yes, please list the types of surgeries and the approximate dates.
- Family History (Paragraph)Note any hereditary or chronic illnesses running in your family (e.g., diabetes, heart disease).
- Wake Up Time (Short answer)What time do you typically wake up in the morning?
- Exercise Frequency (Dropdown)How often do you engage in physical exercise or yoga?
- Appetite Status (Multiple choice)Describe your general appetite and digestion.
- Daily Food Chart (Paragraph)Provide a brief summary of what you typically eat for breakfast, lunch, and dinner.
- Bowel Habits (Paragraph)Describe your bowel movements (frequency, consistency, ease of elimination).
- Sleep Quality (Multiple choice)How would you rate your typical night's sleep?
- Stress Level (Linear scale)Select your average daily stress level.
- Current Ayurvedic Medicine Use (Multiple choice)Are you currently taking any Ayurvedic herbs, supplements, or remedies?
- Ayurvedic Medicines Details (Paragraph)If yes, please list the names of the remedies and dosage.
- Reports / Scanned Reports Upload (Paragraph)Please paste a link to your file (Google Drive, Dropbox, etc.) or describe the document you wish to attach.
FAQ
How do I customize this form for my practice?
Once you convert the template using Doc2Form, you can freely edit any question, add your clinic branding, or adjust options directly within Google Forms.
Can patients upload scanned medical reports or test results?
Yes. The form includes dedicated sections where patients can paste links to digital reports, lab results, or imaging files.
Is this form template free to use?
Yes, this template is completely free to convert and deploy as a Google Form.
Can I collect patient responses on any device?
Google Forms automatically formats your intake form for mobile phones, tablets, and desktop computers so patients can fill it out easily from anywhere.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.