Ayurvedic Medication/Herbal Formulation Prescription

Ayurvedic Formulation Prescription

Status: [Final / DRAFT — pending signature]

Document Header

Date/Time: [Date and time]

Patient Name: [Full name]

DOB: [MM/DD/YYYY]

Prescriber: [Name, credentials, clinic, contact]

Clinical Indication

• [Primary symptom or condition in plain language]
• [Measurable treatment goal] (E.g., reduced frequency/severity or improved function.)
• [Ayurvedic assessment summary if established] (Optional; include relevant dosha/agni/prakriti only if previously determined.)

Formulation Orders

Formulation [#]

Product: [Product name as on label; classical name in parentheses if different] — [dosage form: tablet/vati / powder/churna / decoction/kwath / liquid: asava/arishta / ghee/ghrita / oil/taila / capsule / other] — [strength/concentration if known] — [manufacturer/brand] — [Lot/Batch No. and Expiration if available, especially for herbomineral formulations]

Patient Directions: [Write as one clear sentence: exact dose in familiar units (e.g., "½ teaspoon ≈ 2 grams"), route, frequency with specific times anchored to routine, relation to meals, vehicle/anupana if used, duration, and explicit stop or review date] (Avoid Latin abbreviations. If any element is unconfirmed, leave a bracketed placeholder.)

Counseling:

• [What to expect and timeline for benefit]
• [Storage/handling if non-obvious]
• [Key safety warnings and stop/seek-care symptoms]
• [Interaction cautions] (Screen for anticoagulants, surgery timing, narrow-therapeutic-index medications.)
• [Missed-dose instruction] (Typically: take when remembered unless close to next dose; do not double.)

Formulation [#]

Product: [Product name; classical name if different] — [dosage form] — [strength] — [manufacturer/brand] — [Lot/Batch No. and Expiration if available]

Patient Directions: [Single clear sentence with dose, route, timing, meal relation, vehicle/anupana, duration, stop/review date]

Counseling:

• [What to expect and timeline]
• [Storage/handling]
• [Safety warnings and stop/seek-care symptoms]
• [Interaction cautions]
• [Missed-dose instruction]

(Repeat Formulation block for additional products as needed.)

Daily Schedule Summary

(Include only if two or more formulations are prescribed.)

• Morning: [Formulation name(s) and dose]
• Midday: [Formulation name(s) and dose]
• Evening: [Formulation name(s) and dose]
• Bedtime: [Formulation name(s) and dose]

Safety & Follow-up

Interaction Review: [Confirm medication/supplement list was reviewed for interactions]

High-Risk Flags: [Document only if applicable: pregnancy/lactation, upcoming surgery, anticoagulant therapy, liver/kidney disease, pediatric/geriatric status, heavy-metal–containing formulations]

Follow-up: [Interval and modality] to assess [symptom change, tolerability, adherence]. [After-hours contact if relevant].

Adverse Event Instructions: Stop and contact clinic if [specific warning signs]; seek emergency care for [severe reactions].

Prescriber Signature: [Handwritten or digital signature]

Date/Time Signed: [Date and time]