Diet & Lifestyle Instructions (Pathya/Apathya & Vihara)

Patient Name: [Patient name]

Date of Birth: [MM/DD/YYYY]

Visit Date: [MM/DD/YYYY]

Clinician: [Clinician name, credentials, contact info]

Reason for This Plan: [Brief patient-friendly description of the condition or goal being addressed]

Your Main Focus

Summary: [One-sentence main message stating the overall aim and how to reach it]

Timeframe: Start: [MM/DD/YYYY] | Duration: [# days/weeks] | Next check-in: [date or scheduling instructions]

Your Top Priorities

• ☐ [Priority action 1 with specific target: what, amount, timing, frequency]
• ☐ [Priority action 2 with specific target and frequency]
• ☐ [Priority action 3 with specific target and frequency]
• ☐ [Priority action 4] (Include only if needed; keep total 3–5 items.)
• ☐ [Priority action 5] (Include only if needed.)

Diet: What to Eat & What to Avoid

(If Ayurvedic terms are used: "Pathya" = helpful choices; "Apathya" = foods to avoid or limit. Use English labels below.)

Helpful Choices: [Foods and drinks to eat more often, with portions/frequency as provided]

Avoid or Limit: [Foods or drinks to avoid completely or limit, with specific amounts where applicable]

Meal Timing: [Meal schedule, spacing, or evening cutoff instructions] (Only include if clinician specifies.)

Hydration: [Daily fluid goal or restriction with amount and timing] (Only include if a specific target is provided.)

Supplements: [Product name, dose, timing, duration, purpose, and stop rules for each] (Only include if explicitly recommended. Omit entirely if none.)

Lifestyle: Daily Routine & Activity

Daily Schedule:

• ☐ Wake time: [Target time]
• ☐ Meal times: [Breakfast / Lunch / Dinner times]
• ☐ Screen-off time: [Time] (Only include if specified.)
• ☐ Bedtime: [Target time]

Sleep Guidance: [Wind-down steps, bedroom environment, sleep duration target] (Only include if provided.)

Physical Activity: [Type, frequency, duration, intensity, restrictions/stop rules] (Only include if clinician specifies.)

Stress/Breathwork: [Practice name, steps, timing, duration] (Only include if provided.)

Avoid/Limit: [Alcohol, nicotine, caffeine, late screens, or other exposures to avoid] (Only include items discussed.)

Tracking & Follow-Up

7-Day Tracker

Priority	Day 1	Day 2	Day 3	Day 4	Day 5	Day 6	Day 7
[Priority 1 label]	☐	☐	☐	☐	☐	☐	☐
[Priority 2 label]	☐	☐	☐	☐	☐	☐	☐
[Priority 3 label]	☐	☐	☐	☐	☐	☐	☐
[Priority 4 label]	☐	☐	☐	☐	☐	☐	☐
[Priority 5 label]	☐	☐	☐	☐	☐	☐	☐
Notes/Barriers	[Space for patient to note what helped or got in the way]

When to Call the Clinic

• [Symptom or side effect requiring a call]
• [Unable to meet nutrition/hydration targets for specified duration]
• [Questions about medications/supplements or new side effects]
• [No improvement or worsening after specified timeframe]

Seek Urgent Care If...

• [Red-flag symptom 1 tailored to condition]
• [Red-flag symptom 2 tailored to condition]
• [Red-flag symptom 3 tailored to condition]

(Include 3–6 warning signs as relevant to the patient's condition.)

Next Steps

Follow-up appointment: [Date/time or scheduling instructions]

Pending tests: [Tests and expected dates/results] (Only include if applicable.)

Referrals: [Referrals and contact info] (Only include if applicable.)

Questions for Your Next Visit

• My main concern is: __________________________
• A barrier I expect is: ________________________
• Other questions: _____________________________