Health Seeker Intake
Name
*
Age
*
Sex
*
Male
Female
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.
Physical Stature
*
(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
Chest
*
(V)Thin, small, narrow, small rib cage
(P)Medium
(K)Broad, large, well developed bust
Weight
*
(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
Complexion
*
(V)Dull, Darkish, dusky
(P)Red, flushed, glowing,lustrous
(K)Pale , white
Skin
*
(V)Dry, rough, thin, cold, cracked
(P)Warm, moist, pink, moles, freckles, acne
(K)Cold, damp, thick, soft, smooth
Eyes
*
(V)Small, dry, thin, nervous, brown
(P)medium, sharp, blue or green, piercing
(K)Big, lustrous, oily, attractive
Hands and fingers
*
(V) Small, thin, dry, cold, long
(P) Medium, warm, pink, moist, pointed
(K) Large, thick, cool, firm, stocky
Hair
*
(V) Thin, dry, brittle, dandruff (often)
(P) Fine, oily, early graying or balding
(K) Thick, full, lustrous, wavy
Shape of face
*
(V) Oval, narrow
(P) Triangular, sharp contours
(K) Large, round, soft contours
Lips
*
(V) Thin, small, darkish
(P) Medium, soft, nice curve
(K) Thick, large, smooth, firm
Joints
*
(V) Small, thin, cracking
(P) Medium, soft, loose
(K) Large, thick, deep seated
Nails
*
(V) Thin, rough, brittle, cracked
(P) Soft, pink
(K) Thick, large smooth, white
Sweating
*
(V) Hardly sweat, scanty
(P) Perspires easily,
(K) Only sweats if work hard
Speech
*
(V) Quick, fast, frequent, erratic, talkative
(P) Definite, argumentative, convincing, sharp, cutting
(K) Slow, melodious, not very talkative, good listener
Appetite
*
(V) Variable, erratic, up and down,
(P) Strong, sharp, high, excessive, can’t tolerate hunger
(K) Low, can easily skip a meal,
Bowel Movements
*
(V) Irregular, dry, hard, prone to constipation, gas
(P) Prone to diarrhea, loose, soft, regular
(K) Regular, once or twice a day, formed
Sleep
*
(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
Dreams
*
(V) Dreams often, fearful, flying, jumping, running, nightmares
(P) Often, vivid, colors, passionate, fiery, angry, violent
(K) Romantic, sentimental, calm, watery, few dreams
Emotions
*
(V) unpredictable, nervous, anxious, worrier, fear
(P) Irritable, jealous, blaming, judgmental, angry, critical
(K) Calm, quiet, loving, attachment
Personality
*
(V) nervous, anxious, changes mind, creative, imaginative, expressive
(P) Determined, confident, aggressive, outgoing
(K) Calm, content, happy, lazy, prone to attachment
Decision making
*
(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
Hobbies
*
(V) Dancing, traveling, running, aerobics, action
(P) Sports, politics, debates, winning
(K) Reading, gardening, nature walks (joy)
Actions
*
(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
Stamina/Strength
*
(V) Low stamina, poor endurance, tires easily
(P) Medium
(K) Good endurance, can work for long periods of time
Weather preference
*
(V) Warm, humid
(P) Cooler weather
(K) Warm, dry
Resistance to disorder
*
(V) Weak immune system, frequently get sick
(P) Moderate, sensitive to heat, prone to infections
(K) Strong immune system, does not get sick easily
Disorder tendency
*
(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)
*
Bowel Movement
*
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)
*
1
2
3
4
5
In the morning when I wake up; it takes me quite a while to feel really awake
*
1
2
3
4
5
I tend to feel weak, physically, for no reason that I can see
*
1
2
3
4
5
I get colds (or similar conditions) several times each year
*
1
2
3
4
5
My body tends to have a feeling of heaviness
*
1
2
3
4
5
I just tend to feel that “something isn’t working right” in my body (digestion, breathing, bowel movements, or something else)
*
1
2
3
4
5
I tend to feel lazy (My capacity to work seems alright, but I have no desire)
*
1
2
3
4
5
I commonly have indigestion
*
1
2
3
4
5
I often feel the need to spit
*
1
2
3
4
5
Often, I just don’t have a taste for food, I have a poor appetite
*
1
2
3
4
5
I just tend to feel tired, even exhausted...in mind or body
*
1
2
3
4
5
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)
*
1
2
3
4
5
Can you skip meals easily? (3 or below= Kapha/Ama Manda)
*
1
2
3
4
5
Are you mostly always ready to eat- no matter what time of the day? (3 or below= Pitta/Tikshna)
*
1
2
3
4
5
If hunger is not gratified, do you feel uncomfortable or irritable? (3 or below= Pitta/Tikshna/Vata)
*
1
2
3
4
5
Do you end up feeling fuller earlier than expected at the start of a meal? (3 or below= Ama/Vata/Manda/Vishama)
*
1
2
3
4
5
Are there times when even little quantity of food doesn’t get digested for a long time? (3 or below= Ama/Manda)
*
1
2
3
4
5
Does your food get digested well on some days and sometimes not? (3 or below= Vata/Vishama)
*
1
2
3
4
5
On a scale of 1-10, rate how stressed you have been in the past week.
*
1
2
3
4
5
6
7
8
9
10
11
What is your energy level?
*
1
2
3
4
5
6
7
8
9
10
11
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.
Diet
*
(S) Vegetarian/Vegan
(R) Some meat
(T) Heavy meat diet (daily)
Drugs, Alcohol & Stimulants
*
(S) Never
(R) Occasionally
(T) Frequently
Sensory Impressions (how you digest and translate information received through the 5 senses-the quality of your thoughts and emotions)
*
(S) Calm, pure
(R) Mixed
(T) Disturbed
Need for sleep
*
(S) Little
(R) Moderate
(T) High
Sexual Activity
*
(S) Low
(R) Moderate
(T) High
Control of Senses (sometimes translated as urges, your ability to refrain from unhealthy urges communicated to you through your senses)
*
(S) Good
(R) Moderate
(T) Weak
Speech
*
(S) Calm and peaceful
(R) Agitated
(T) Dull, monotone
Cleanliness
*
(S) High
(R) Moderate
(T) Low
Work
*
(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
Anger
*
(S) Rarely
(R) Sometimes
(T) Frequently
Fear
*
(S) Rarely
(R) Sometimes
(T) Frequently
Desire
*
(S) Little
(R) Some
(T) Much
Pride
*
(S) Modest
(R) Some ego
(T) Vain
Depression
*
(S) Never
(R) Sometimes
(T) Frequently
Love
*
(S) Universal
(R) Personal
(T) Lacking in love
Violent Behavior
*
(S) Never
(R) Sometimes
(T) Frequently
Attachment to money
*
(S) Little
(R) Some
(T) A lot
Contentment
*
(S) Usually
(R) Partly
(T) Never
Forgiveness, ability to let go and move forward
*
(S) Forgives easily
(R) With effort
(T) Holds long term grudges
Concentration
*
(S) Good
(R) Medium
(T) Poor
Memory
*
(S) Good
(R) Moderate
(T) Poor
Willpower
*
(S) Strong
(R) Variable
(T) Weak
Truthfulness (making known all the truth of a matter, free of omission)
*
(S) Always
(R) Most of the time
(T) Rarely
Honesty (not telling lies)
*
(S) Always
(R) Most of the time
(T) Rarely
Peace of Mind
*
(S) Generally
(R) Partly
(T) Rarely
Creativity
*
(S) High
(R) Moderate
(T) Low
Spiritual study
*
(S) Daily
(R) Occasionally
(T) Never
Mantra, Prayer
*
(S) Daily
(R) Occasionally
(T) Never
Meditation
*
(S) Daily
(R) Occasionally
(T) Never
Service to others
*
(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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