Ayurvedic Consultation Form

Thank you for choosing to work with me. Please take few moments to tell me about yourself. Fill out and submit the form 2 days before our scheduled appointment:

Full Name *

Date of Birth *

Age *

Phone *

Email *

Address *

Occupation / Job

Relationship Status

Single

Married

In a Relationship

Separated

Devorced

Widowed

OtherOther

Height *

Weight *

List your current health problems: *

Check symptoms that apply: *

Headaches

Digestive Problems

Dizziness

Itching / Rashes

Numbness

Short Breath

Sleep Disorders

Back Pain

Neck Pain

Nausea / Vomiting

Depression

Current workouts per week *

5-7 Days a week

3-4 Days a week

1-2 Days a week

I don't workout

Workout duration *

45+ Minutes duration workout

30-45 Minutes duration workout

Less than 30 minutes

Type of workouts *

Walking

Swimming

Hiking

Running, Jogging

Basketball

HIIT

Yoga

Football

Pilates

Weight Lifting

Boxing

Dancing

Diet Preference *

Mixed Food Diet (animal & plant sources)

Vegetarian (eats eggs and dairy products but not meat or fish)

Vegan (doesn't eat any animal products)

Pescatarian (vegetarian that eats fish & seafood, no meat)

Low Carb Diet

Low Fat Diet

Low Salt Diet

Gluten Free

Dairy Free

Paleo

Specific Food Restrictions / Allergies:

Wheat / Gluten

Eggs

Soy

Nuts

Sugar

Dairy / Milk

Checkboxes *

3 meals a day

2 meals a day

1 meal a day

Skips breakfast

Snacks a lot between meals

Eats constantly whether hungry or not

Generally, eats on the go while distracted

Grazer (eats small frequent meals)

Adds extra salt to food

Overeats at every meal

Check the level of stress you are experiencing (1 being low, 10 being high): *

Are you on any medications? *

Yes

Do you take supplements?

Yes

What supplements?What supplements?

Mind-Body Type Questionnaire

Maybe the past week was unusual for you, but we are looking to identify the basic structure of your personality and body.

Height *

1. Tall and lanky or petite

2. Average height

3. Short and round or tall and broad

Weight *

1. Low, hard to gain weight

2. Moderate, gains or loses weight easily

3. Heavy, hard to lose weight

Frame *

1. Thin, boney

2. Medium frame

3. Large or round, thick bones

Skin Type *

1. Dry, thin, rough, cold hands and feet

2. Warm, oily, sensitive, prone to acne or rashes

3. Cold, soft, thick, clear, plump

Skin Complexion *

1. Dull, tanned, darkish

2. Rosy, reddish

3. White or pale

Hair Type *

1. Dry, rough, prone to dandruff

2. Oily, soft, prone to hair fall

3. Thick, wavy, full, shiny

Eyes *

1. Small, move fast

2. Piercing, easily inflamed, prone to redness

3. Large, bright white

Teeth *

1. Small, crooked, poorly formed

2. Medium, tendency to bleeding gums

3. Large, well formed

Sweating *

1. Hardly sweats

2. Very sweaty, can have a strong body odor

3. Sweats moderately

Stools *

1. Hard or dry, tendency for constipation (eliminates less than once a day)

2. Soft, loose, tendency for diarrhea (eliminates more than 3 times a day)

3. Large, can be sticky, regular (eliminates once a day)

Urination *

1. Small amount

2. Plenty

3. Moderate

Sensitivities to Temperature *

1. To cold, dryness and wind

2. To heat, sunlight and sunburns

3. To humidity

Weather Preference *

1. Prefers hot weather (Loves Summer)

2. Prefers cold weather (loves Winter)

3. Prefers dry and warm weather (dislikes humidity)

Immune Function *

1. Low, always sick

2. Moderate, gets the flu once or twice a year

3. High, strong, rarely sick

Disease Tendency *

1. Pain in joints, muscles and bones

2. Fever, inflammations

3. Allergies, asthma, water retention

Activity Levels *

1. Hyper-active, restless, can't sit still

2. Moderate

3. Low, moves slowly

Endurance and Stamina *

1. Low, gets tired and depleted easily

2. Moderate, gets exhausted after few hours

3. High, always has some energy left for more

Sleep *

1. Poor, light, disturbed (6 or less hours of interrupted sleep)

2. Normal (around 8 hours of sound sleep)

3. Excessive (sleeps deeply for more than 8 hours)

Memory *

1. Forgetful

2. Clear

3. Good-long term

Dreams *

1. Frequent, involves running, flying or supernatural scenes

2. Moderate, involves real-life scenes and problem solving

3. Infrequent, don't remember dreams

Speech *

1. Talkative, talks fast

2. Sharp, clear speech

3. Slow, deep voice

Temperament *

1. Nervous, moody

2. Usually motivated but can become irritated

3. Balanced, calm, stable

Motivation *

1. Variable, changing

2. Strong, determined

3. Moderate, steady

Sense of Ego *

1. Erratic, prone to extremes

2. Strong, fixed, proud

3. Based on family, surroundings, feedback

Sensitivity *

1. Hypersensitive, easily hurt

2. Insensitive

3. Carefree, self-content

Emotional Tolerance *

1. Impulsive, reacts quickly

2. Resistant, argues and doesn't let go

3. Hard to disturb, forgiving

Ability to Handle Stress *

1. Very little, breaks down easily

2. Moderate, becomes angry

3. Handles well, ignores

Anger *

1. Unpredictable

2. Quick to get angry

3. Slow to get angry

Attachment *

1. Changing, detached

2. Fairly independent

3. Attached, unable to let go

Depression *

1. Extreme highs and lows

2. Based on sense of failure

3. Based on sense of emotions

Anxiety *

1. High, always anxious

2. Rare

3. Sometimes, when feeling out of balance

Addictions and Obsessions *

1. Entertainment, media

2. Alcohol, caffeine, power

3. Food, possessions, people

Lifestyle or Daily Schedule *

1. Irregular, dislikes routines

2. Organized, planned

3. Routine, doesn't like change

Relationships *

1. Changeable, passing, many casual

2. Close, strong, dominating, intense

3. Steady, loyal, trusting, long lasting

Social Temperament *

1. Rebel, innovator, artistic, creative, dreamer

2. Leader, manager, fanatic, doer

3. Nurturer, provider, conservative, protector

Hunger Levels *

1. Irregular, either very hungry or not hungry at all

2. Strong, needs food when hungry

3. Regular, can easily skip meals

Sex Drive

1. Low

2. Moderate

3. Strong

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Ayurvedic Consultation Form

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