Patient Info

Name:

Visit Date:

Prakruthi & Vikruthi

Prakruthi balance:

Current Vikruthi:

Vikrutha Dosha Summary

Dosha Quantity Guna Affected Kriya Kala Stage

Agni Status

Agni Type Status

Samprapthi Analysis

Total Samprapthi:

Samprapthi # Kriyakala Dosha(s) Sub-dosha(s) Dushya(s) Roga Marga

Dhatu Analysis

Nourishment Status of Dhatus

Dhatu Status

Dhatwagni State in Each Samprapthi

Samprapthi # Involved Dhatu Dhatwagni State

Guna Analysis

Predominant Guna Mapping

Category Component Predominant Guna

Samprapthi-wise Predominant Guna

Samprapthi # Predominant Guna(s)

Comparative Quantitative Guna Distribution

Guna Samprapthi 1 (%) Samprapthi 2 (%)

Dosha Sthana Analysis

Before Samprapthi (From Vikruthi)

Dosha Udhbhava Sthana (Chaya/Prakopa) Sanchara Sthana (Prasara) Vyaktha Sthana (Sthana Samshraya)

During Samprapthi

Samprapthi # Dosha Udhbhava Sthana Sanchara Sthana Vyaktha Sthana

Recommendations

Diet Protocol

    Herbal Formulations

      Lifestyle & Therapies

        Follow-up Goals