Aarogyam Health & Wellness Centre

Dr. Richa Garg,

Ayurvedic Nutrition Consultant
#, A-1/4, Sector-11, Rohini,
New Delhi-110085, aaarogyam.wellness@gmail.com
DATE :
NAME :
AGE:
SEX:
REF. BY :
DATE OF BIRTH:
OCCUPATION:
ADDRESS:
PHONE NO AND ALTERNATE CONTACT NO.
EMAIL ID:
WEIGHT IN KG:
HEIGHT IN CMS:
BLOOD GROUP :
MEDICAL HISTORY WITH MEDICINES AND SUPPLEMENTS( IF ANY)

FAMILY HISTORY OF
DIABETES:
HIGH BLOOD PRESSURE:
CARDIAC PROBLEM:
COPD/ASTHMA:
OBESITY :
THYROID :
ARTHRITIS :
H/O WEIGHT GAIN(PROBABLE REASON)

PAST H/O WEIGHT LOSS METHODS USED OR PROG. JOINED EARLIER WITH RESULT
BLOOD PRESSURE
MENSTRUAL HISTORY(FOR FEMALES ONLY)
DATE OF LAST PERIODS:
REGULAR/IRREGULAR:
NO OF DAYS:
CYCLE DURATION:

PRE-MENSTRUAL SYMPTOMS

DIETRY FACTS
VEG/NON VEG(frequency of eggs/non-veg)
FOOD ALLERGY:
FOOD LIKES:
FOOD DISLIKES:
TRAVEL :
SWEET TOOTH:
PAN/SUPARI:
ALCOHOL:
SMOKING:
EAT OUT :
ICE CREAM:
CHOCOLATE:
SOFT DRINK :
TEA/COFFEE/MILK:(quantity of sugar in it)
OIL USED FOR COOKING:
TOTAL WHITE SUGAR USED PER DAY:
ROUTINE DIET MENU WITH QUANTITY IN EACH MEAL
WAKE UP TIMINGS :
EARLY MORNING:
BREAKFAST: (
7-7.15
)
MID- MORNING:(
9.40
)
LUNCH: (
2
)
MID-EVENING:(
4-5
)
DINNER:(
8-9
)
POST DINNER :(
11-12
)TOTAL WATER INTAKE PER DAY
ANY OTHER INFORMATION YOU WOULD LIKE TO
PROVIDE
PHYSICAL ACTIVITY WITH DURATION(PRESENT AND PAST)
MEASUREMENTS(IN CENTIMETERS)
CHEST
WAIST(just below chest)
ABDOMEN(navel point)
HIPS:
ARM (uppermost)
THIGH (uppermost)

MEDICAL CLINICAL PARAMETERS

ENERGY LEVELS:
SKIN :
CONSTIPATION :
GAS :
ACIDITY :
WATER RETENTION /BLOATING :
JOINT PAIN :
EMOTIONAL EATING :
SUGAR CRAVING :
FOOD CRAVINGS :
HEADACHE :
BACKACHE :
OTHER PROBLEMS:
BLOOD INVESTIGATION REPORT WITH DATE(IF ANY DONE EARLIER)
HB:
TOTAL CHOLESTEROL:
HDL:
LDL:
VLDL:
TG :
FASTING BLOOD SUGAR:
SGOT :
SGPT :
ALK PHOSP :
BLOOD UREA :
URIC ACID :
TSH :
INSULIN FASTING :
CONSTITUTION FORM
1 SKIN

2. HAIR

3 THIRST

4 ACTIVITY

5 WEIGHT

6 BODY FRAME

7 APPETITE

8 VOICE

9 SPEECH

10 SLEEP

11 TEMPRAMENT

12 DECISION

13 MEMORY

14 MOOD

15 WEATHER

16 BODY TEMPRATURE

17 SWEATING

18 PULSE

19 TASTE

20. DIGESTION EVACUATION

SIGNATURE OF PATIENT

Consent For the Health program

I, .................................., authorize Arogyam Team, to help me

in my weight management efforts. I understand that my health
program may consist of a balanced diet, regular exercise,
instruction in behaviour modification, and the use of some
kitchen herbs
I understand that much of the success of the program will
depend on my efforts and there are no guarantees or
assurances that the program will be successful.
I agree that in any case I wont be able to follow the program
fee is not refundable and non- extendable.
I also understand that obesity may be a chronic, life-long
condition that may require changes in eating habits and
permanent changes in behaviour in order to be treated
successfully.

I realize that I should not sign this consent form unless all
the subjects addressed in the form have been adequately
explained to me. If you have any questions regarding the risks
and hazards of the propose treatment, or any questions
whatsoever concerning the proposed treatment or other
treatments, ask Arogyam team now before signing this consent
form.

By signing this document I attest and agree that I have read

and fully understand this consent form and its subject matter,
that my questions have been answered to my complete
satisfaction, acknowledge that I have been urged to ask any
questions I have, and that I have been given adequate time to
read this consent form.
Date & Time:

Health & Wellness Centre

Dr. Richa Garg,

Ayurvedic Nutrition Consultant

#, A-1/4, Sector-11, Rohini,
110085, aaarogyam.wellness@gmail.com
11/5/2015
ABHA
32
FEMALE
17-11-1982
MANAGER
28A JIA SARAI NEAR IIT DELHI, HAUZKHAS NEW DELHI
9999334700
ABHAAMALIK@GMAIL.COM
84
160

A+
Y WITH MEDICINES AND SUPPLEMENTS( IF ANY)

FAMILY HISTORY OF
NO
YES
NO
NO
YES
NO
NO
WEIGHT GAIN(PROBABLE REASON)

ETHODS USED OR PROG. JOINED EARLIER WITH RESULTS

BLOOD PRESSURE

TRUAL HISTORY(FOR FEMALES ONLY)

20-Apr-15
IRREGULAR
NOT FIXED
NOT FIXED

ABDOMINAL CRAMPS, IRRITABILITY

DIETRY FACTS
VEG
NO
ROAD SIDE FOODS

NO
NO
NO
YES
YES
YES
NO
YES 1 TB SPN IN ONE CUP OR GLASS
DESI GHEE
2-3 TB SPOON
DIET MENU WITH QUANTITY IN EACH MEAL
7:00 AM

WATER
BREAK FAST AT 8.30 AM MILK / ONE CHAPATI/TWO BREADS
TEA
LUNCH AT 2 PM TWO CHAPATIS OR RICE WITH SABJI+CURD
TEA
2-3 CHAPATIS WITH DAL OR SABJI
SOME TIMES
TOTAL WATER INTAKE PER DAY

TIVITY WITH DURATION(PRESENT AND PAST)

EASUREMENTS(IN CENTIMETERS)
40
37
46
40
14
23

MEDICAL CLINICAL PARAMETERS

YES

NO
YES
YES
YES
NO
NO

TION REPORT WITH DATE(IF ANY DONE EARLIER)

NORMAL
VERY HIGH

HIGH
CONSTITUTION FORM
1 SKIN
dry
Oily, prone to acne, sun burn easily
Cool, smooth, moist
2. HAIR
dry, brittle, slightly wavy,PREMATURE GREY
Fine, straight, premature grey, oily
Thick, dark, smooth
3 THIRST
variable, erratic
Excessive
Low
4 ACTIVITY
active, restless, energy comes in burst
Moderate, focused average stamina
Lethargic, slow, stamina is good

5 WEIGHT
loose easily, hard to gain
Put on and loose easily
Gain easily and loose slowly
6 BODY FRAME
small
Medium
Large
7 APPETITE
Variable, low
Medium
Moderate
8 VOICE
fast, rapid, quick
Commanding, sharp
Soft, sweet, not talkative
9 SPEECH
erratic, fast, husky
Decisive, easily audible
Slow and deliberate
10 SLEEP
light, suffers from insomnia
Light, enjoy good night sleep
Heavy sound, for long hours
11 TEMPRAMENT
Nerous, Fearful
Irritable, impatient
Easy going
12 DECISION
difficulty in making decision
Decisive, logical, forceful &generally dont change
Thoughts and actions are well planned
13 MEMORY
grasp quickly forget quickly
Sharp and clear
Slow to learn but retains
14 MOOD
changes easily, quickly, often take on project that dont complete
Well organized, perfectionist, enjoy challenges and achieving Often
goals
Relaxed, regular lifestyle, complete project that start
15 WEATHER
cold, dry weather bothers, prefer warm
Heat, sun bothers, perspires easily, prefer cold
Cold damp weather bothers

16 BODY TEMPRATURE
Cold hand and feet
Hot
Normal
17 SWEATING
minimal
Excessive with pungent smell
Heavy without odour
18 PULSE
irregular
Regular/bounding
Regular smooth
19 TASTE
sweet, sour, salty
Sweet, bitter, astringent, raw, slightly cooked
Pungent, bitter food without oil
20. DIGESTION EVACUATION
often constipated
Bowel more than once
Usually once, watery
SIGNATURE OF PATIENT

sign: