Ayurveda Initial Consultation Note (Prakriti/Vikriti Assessment)

Patient Name: [Patient full name]

DOB: [Date of birth]

MRN: [Medical record number]

Date of Service: [Date]

Start/End Time: [Start time] – [End time]

Location: [in-person / telehealth / home visit / other]

Clinician Name and Credentials: [Name, credentials]

Sources of History: [patient / caregiver / prior records reviewed / questionnaires completed]

Chief Concern & Patient Goals

[Patient-stated reason for visit] (Use direct quotes for key phrases. If multiple concerns, list in patient-priority order.)

• Patient goals: [What success looks like to the patient]
• Treatment preferences/constraints: [Dietary restrictions, cultural preferences, budget, time limitations, therapies to avoid] (Include only if discussed.)

History of Present Illness

[Opening statement with patient context and chief concern]

[Chronology: onset, course, triggers, relieving factors, severity, frequency, functional impact, prior evaluations and treatments with response, relevant context including recent changes in diet, sleep, activity, stress, supplements]

Doshic Qualities (Clinician Interpretation): [Observed qualities relevant to Ayurvedic reasoning: dryness/oiliness, heat/cold, heaviness/lightness, time-of-day patterns, seasonality, appetite/bowel rhythms] (Clearly label as clinician interpretation; omit if not applicable.)

Red flags: [present (describe) / absent / not assessed]

Pregnancy status: [pregnant / not pregnant / unknown / not applicable]

Medication list completeness: [complete / partial / unknown]

Past History

Past Medical History: [Chronic conditions, prior diagnoses, hospitalizations; include integrative-relevant conditions such as thyroid, autoimmune, GI, mood/eating disorders, pregnancy/postpartum]

Surgical History: [Surgeries, major procedures, implanted devices]

Medications, Supplements & Ayurvedic Products: [List all prescription, OTC, supplements, and herbs with name, dose, frequency, indication; include brand/manufacturer for Ayurvedic products when known; flag safety-sensitive medications; note whether bottles/photos/list were provided]

Allergies: [Drug/supplement/food allergies and intolerances with reaction type; distinguish true allergy vs intolerance; if unknown, state "Allergies: not obtained"]

Family History: [Heritable risks: cardiometabolic, autoimmune, psychiatric, cancer]

Social History: [Occupation and schedule constraints, stressors, physical activity, substance use, sleep patterns, social determinants affecting adherence]

Review of Systems

[Focused review aligned to presenting concerns and safety screening; use pertinent positives and negatives by system; include "denies" statements only when they meaningfully narrow the differential] (Do not include systems with no relevant findings.)

Prakṛti and Vikṛti Assessment

Prakṛti (Baseline Constitution)

• Assessment method: [questionnaire (name/version) / interview / clinical assessment]
• Determined constitution: [vāta / pitta / kapha / vāta-pitta / pitta-kapha / vāta-kapha]
• Confidence level: [high / moderate / low]
• Supporting features: [Body frame, thermoregulation, appetite pattern, stress response, sleep traits]
• Potential confounders: [Acute illness, pregnancy/postpartum, steroid use, severe sleep deprivation, other] (If assessment deferred, state reason.)

Vikṛti (Current Imbalance)

• Primary dosha involvement: [vāta / pitta / kapha]; Secondary: [vāta / pitta / kapha / none]
• Affected systems/domains: [GI, skin, musculoskeletal, mood, sleep, metabolism, other]
• Severity: [mild / moderate / severe]; Chronicity: [acute / subacute / chronic]; Pattern: [stable / fluctuating]
• Supporting symptoms/signs: [Brief list linking observed features to the imbalance]

Digestive Assessment (Agni/Āma)

• Appetite and timing: [regular / variable / poor / excessive] — [hunger cues and meal patterns]
• Post-meal symptoms: [bloating / heaviness / reflux / fatigue / none / other]
• Stool pattern and qualities: [Frequency, form, completeness]
• Clinician impression: [Agni status and presence/absence of āma with supporting evidence]

Classical Examination Findings

(Include only elements actually performed; omit this subsection entirely if no classical examination was done.)

• Pulse (nāḍī): [Rate, rhythm, qualities relevant to doshic interpretation]
• Tongue (jihvā): [Body color/shape, coating, moisture]
• Skin/complexion: [Texture, temperature, moisture]
• Voice/speech: [Tone, pace, clarity]

Objective

Vitals: BP [value], HR [value], RR [value], Temp [value], SpO₂ [value], Wt [value], Ht [value], BMI [value] (Indicate source: clinic measurement / home device / patient report. If not obtained, state reason.)

Physical Examination: [General appearance and system-focused findings aligned to presenting concerns] (Document only what was examined.)

Diagnostics Reviewed: [Labs, imaging, questionnaire scores, device data with dates and interpretation] (Omit if none reviewed.)

Assessment

(Number problems in order of clinical severity.)

1. [Problem name]: [Working diagnosis (biomedical and/or Ayurvedic)]; [new / uncontrolled / improving / stable]
   • Supporting data: [Relevant symptoms, exam, and objective findings]
   • Differential: [Alternatives considered] (Include only if diagnosis uncertain.)
2. (Additional problems as needed, following same format.)

Prakṛti/Vikṛti Synthesis: [Concise paragraph linking constitutional tendencies to current imbalance and how this informs treatment approach] (Avoid implying biomedical causality unless evidence-based.)

Red flags: [absent / present — describe findings, urgent referral guidance, and patient understanding]

Plan

(Organize by problem number. Include only applicable elements for each problem. Distinguish recommendations from what patient agreed to.)

1. [Problem 1]
   • Diagnostics: [Labs, imaging, symptom logs with rationale] (If applicable.)
   • Diet (Āhāra): [Principles and specific starting steps: meal timing, hydration, foods to favor/limit, cooking methods; note cultural preferences and feasibility]
   • Daily Regimen (Vihāra): [Sleep schedule targets, movement plan, stress practices with frequency and duration] (Prioritize 1–3 high-yield behaviors.)
   • Herbs and Supplements: [Product name (common and Latin), formulation, brand/manufacturer, dose, route, schedule, duration, intended effect; document interaction screening, contraindications, pregnancy/lactation/hepatic/renal considerations, quality/sourcing notes, expected timeline, potential adverse effects, and stop rules]
   • Body Therapies: [Indication, modality, frequency, precautions, provider] (Include only if recommended and within scope.)
   • Monitoring: [Symptoms and adverse effects to track, thresholds for action, contingency if worsening or non-response]
   • Referrals: [PCP / specialist / mental health — reason, urgency, requested evaluation] (If applicable.)
   • Informed Consent: [Risks, benefits, alternatives discussed for key interventions; patient questions; agreement or refusal]
2. (Additional problems as needed, including only applicable elements.)

Follow-Up: [Timing, modality, data to bring (logs, labs), criteria for earlier contact]

Signature

[Electronic signature], [Date and time]