Mind-Body Constitution Analysis

Health Seeker Intake
Name*
Age*
MaleFemale
Weight*
Height*
General Health Concerns (Main problems you would like help with)*
Dosha Analysis

Please give answers based on your long term tendencies meaning your natural tendencies over your whole lifespan, not tendencies as of late, or with illness and dis-ease present. Make sure to answer the questions honestly, (this is so important) and not answers you wish to be true. Try your best to pick the best one option that most applies and only pick multiple if they equally apply.
(V)I am thin, lanky, and slender, prominent joints and thin muscles(P)I am medium build, good muscle development(K)I have large, round, or stocky build, farm is broad, stout or thick
(V)Thin, small, narrow, small rib cage(P)Medium(K)Broad, large, well developed bust
(V)Light weight, hardly gain (gain by ounces, loose by pounds), If gained, can easily loose, I may forget to eat(P)Medium weight, average, good muscles, easy for me to gain or lose weight if I put my mind to it(K)Heavy, easy to gain, very difficult to loose
(V)Dull, Darkish, dusky(P)Red, flushed, glowing,lustrous(K)Pale , white
(V)Dry, rough, thin, cold, cracked(P)Warm, moist, pink, moles, freckles, acne(K)Cold, damp, thick, soft, smooth
(V)Small, dry, thin, nervous, brown(P)medium, sharp, blue or green, piercing(K)Big, lustrous, oily, attractive
(V) Small, thin, dry, cold, long(P) Medium, warm, pink, moist, pointed(K) Large, thick, cool, firm, stocky
(V) Thin, dry, brittle, dandruff (often)(P) Fine, oily, early graying or balding(K) Thick, full, lustrous, wavy
(V) Oval, narrow(P) Triangular, sharp contours(K) Large, round, soft contours
(V) Thin, small, darkish(P) Medium, soft, nice curve(K) Thick, large, smooth, firm
(V) Small, thin, cracking(P) Medium, soft, loose(K) Large, thick, deep seated
(V) Thin, rough, brittle, cracked(P) Soft, pink(K) Thick, large smooth, white
(V) Hardly sweat, scanty(P) Perspires easily,(K) Only sweats if work hard
(V) Quick, fast, frequent, erratic, talkative(P) Definite, argumentative, convincing, sharp, cutting(K) Slow, melodious, not very talkative, good listener
(V) Variable, erratic, up and down,(P) Strong, sharp, high, excessive, can’t tolerate hunger(K) Low, can easily skip a meal,
(V) Irregular, dry, hard, prone to constipation, gas(P) Prone to diarrhea, loose, soft, regular(K) Regular, once or twice a day, formed
(V) Poor, insomnia, disturbed, difficulty falling asleep, wake easily(P) Sound sleeper, easily falls asleep, can feel rested with less than 8 hours(K) Heavy sleeper, slow to rise, excess sleep
(V) Dreams often, fearful, flying, jumping, running, nightmares(P) Often, vivid, colors, passionate, fiery, angry, violent(K) Romantic, sentimental, calm, watery, few dreams
(V) unpredictable, nervous, anxious, worrier, fear(P) Irritable, jealous, blaming, judgmental, angry, critical(K) Calm, quiet, loving, attachment
(V) nervous, anxious, changes mind, creative, imaginative, expressive(P) Determined, confident, aggressive, outgoing(K) Calm, content, happy, lazy, prone to attachment
(V) Changes mind often, decision not well considered(P) Easy to make a decision and stick to it(K) Hard to make decisions, prefers others to make decisions and lead
(V) Dancing, traveling, running, aerobics, action(P) Sports, politics, debates, winning(K) Reading, gardening, nature walks (joy)
(V) Quick, fast, unsteady in bursts, hyperactive, always on the go, spontaneous, do first(P) Precise, orderly, thoughtful, motivated, purposeful, list maker, planned, think first(K) Slow, steady, relaxed, graceful, doesn’t like to rush, likes to follow, not plan
(V) Low stamina, poor endurance, tires easily(P) Medium(K) Good endurance, can work for long periods of time
(V) Warm, humid(P) Cooler weather(K) Warm, dry
(V) Weak immune system, frequently get sick(P) Moderate, sensitive to heat, prone to infections(K) Strong immune system, does not get sick easily
(V) Pain, arthritis, mental disorders, nervous system disorders(P) Infections, inflammatory disorders, fevers, blood disorders, liver disorders(K) Respiratory disorders, mucus, water retention, swelling
Current Experiences
Appetite (Please describe your appetite in your own words, there is no wrong answer here)*
Sleep (list any irregularities- hard to fall, hard to rise, heavy sleep, light sleep, how many hours a night)*
Constipated (takes effort and time)Normal (Evacuate easily and well formed but soft)Diarrhea (or loose)Variable
Urine (color, frequency, irregular smell)*
Females-Menstrual Cycle (List any irregularities or abnormalities)*
Females-Last Menstrual Period*
Previous Health/Family History*
Current Medications/Supplements/Vitamins *
Please list any medical conditions you are diagnosed with*
Āma Questionnaire (Please rate using key below)

1: Never 2: Rarely 3. Sometimes 4. Often 5. Always
I tend to feel blocked in my body (congested in the head, general lack of clarity, or other)*
In the morning when I wake up; it takes me quite a while to feel really awake*
I tend to feel weak, physically, for no reason that I can see*
I get colds (or similar conditions) several times each year*
My body tends to have a feeling of heaviness*
I just tend to feel that “something isn’t working right” in my body (digestion, breathing, bowel movements, or something else)*
I tend to feel lazy (My capacity to work seems alright, but I have no desire)*
I commonly have indigestion*
I often feel the need to spit*
Often, I just don’t have a taste for food, I have a poor appetite *
I just tend to feel tired, even exhausted...in mind or body*
Agni/Āhāra shakti (Ability to eat and digest)

The ability to eat and digest in time greatly influences overall health, that is the metabolic and digestive strength! Since in Ayurveda digestion is key, correcting digestion is top priority in healing disease and correcting imbalances as well as preventing disease.
Rate below how hungry you feel at different meal times. (0=none, 1-3 mildly hungry, 4-7 moderately hungry, 8-9 extremely hungry, 10- HANGRY) and please include the time you have each meal you rate, if you skip that meal just write “skip”. Lastly, please list the kinds of things you eat and/or drink during each meal time.

Example: Morning: 9am, 7 hunger, oatmeal, apples, orange juice, toast with butter and jelly
Morning- Breakfast (List time, hunger rating, and what’s consumed)*
Mid-Morning (List time, hunger rating, and what’s consumed)*
Lunch (List time, hunger rating, and what’s consumed)*
Snack-after lunch (Time, hunger rating, and what’s consumed)*
Evening/Dinner (Time, hunger rating, and what’s consumed)*
Bedtime (Time, hunger rating, and what’s consumed if anything)*
Rate questions below:

1=Always, 2= Often, 3= Sometimes, 4= Rarely, 5= Never
Is the above eating pattern irregular? (3 or below= Vata/Vishama)*
Can you skip meals easily? (3 or below= Kapha/Ama Manda)*
Are you mostly always ready to eat- no matter what time of the day? (3 or below= Pitta/Tikshna)*
If hunger is not gratified, do you feel uncomfortable or irritable? (3 or below= Pitta/Tikshna/Vata)*
Do you end up feeling fuller earlier than expected at the start of a meal? (3 or below= Ama/Vata/Manda/Vishama)*
Are there times when even little quantity of food doesn’t get digested for a long time? (3 or below= Ama/Manda)*
Does your food get digested well on some days and sometimes not? (3 or below= Vata/Vishama)*
On a scale of 1-10, rate how stressed you have been in the past week.*
What is your energy level?*
Mental Constitution

Please complete this form in it’s entirety and with 100% honesty. After completing, have someone who knows you well (spouse or close friend) also fill it out for you, notice the difference between how you view yourself and how others see you. This is also to help you ensure the answers you turn in are completely honest.
(S) Vegetarian/Vegan(R) Some meat(T) Heavy meat diet (daily)
(S) Never(R) Occasionally(T) Frequently
(S) Calm, pure(R) Mixed(T) Disturbed
(S) Little(R) Moderate(T) High
(S) Low(R) Moderate(T) High
(S) Good(R) Moderate(T) Weak
(S) Calm and peaceful(R) Agitated(T) Dull, monotone
(S) High(R) Moderate(T) Low
(S) Selfless (to help others, charities, not about money)(R) For personal goals (Main focus or goal is for material/financial/status gain)(T) Lazy
(S) Rarely(R) Sometimes(T) Frequently
(S) Rarely(R) Sometimes(T) Frequently
(S) Little(R) Some(T) Much
(S) Modest(R) Some ego(T) Vain
(S) Never(R) Sometimes(T) Frequently
(S) Universal(R) Personal(T) Lacking in love
(S) Never(R) Sometimes(T) Frequently
(S) Little(R) Some(T) A lot
(S) Usually(R) Partly(T) Never
(S) Forgives easily(R) With effort(T) Holds long term grudges
(S) Good(R) Medium(T) Poor
(S) Good(R) Moderate(T) Poor
(S) Strong(R) Variable(T) Weak
(S) Always(R) Most of the time(T) Rarely
(S) Always(R) Most of the time(T) Rarely
(S) Generally(R) Partly(T) Rarely
(S) High(R) Moderate(T) Low
(S) Daily(R) Occasionally(T) Never
(S) Daily(R) Occasionally(T) Never
(S) Daily(R) Occasionally(T) Never
(S) Much(R) Some(T) None
Readiness and Willingness

Please answer these few questions as a way to self-analyze and determine your readiness and willingness to make a positive change and invest in your overall health. This also gives me an idea of where you are currently in your journey. Are you ready to take complete control of your mental, physical and spiritual health?
What results are you looking to achieve *
What have you already tried?*
What gets in your way of achieving that goal? What are your obstacles?*
How ready are you to make this lifestyle change?*
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Health Seeker Intake

Dosha Analysis

Current Experiences

Āma Questionnaire (Please rate using key below)

Agni/Āhāra shakti (Ability to eat and digest)

Rate questions below:

Mental Constitution

Readiness and Willingness