Part 1: Ayurvedic Wellness Questionnaire

My name is Elly and I'm very much looking forward to meeting you to review your health concerns and create an ongoing plan for your wellbeing. I recommend you complete this wellness questionnaire on your computer. This form does not autosave but you can save it at the bottom of the page and return to it at a later time. Saving every 15 or 30 minutes and each time you need to step away from your computer is a nice idea.You may want to set aside 60-120 minutes to answer the questions clearly and honestly.

The more information you can provide, the more thorough I can be with my recommendations. I am aware that some some of the information you provide may be very sensititive. I can assure you that all of the information on this form will be kept completely confidential and will be treated with the utmost respect.

Note that towards the end of the questionnaire you will need to upload a video of your tongue and pictures of your face and your body (front and side views, in form-fitting or Yoga clothes). I use these photos to get a deeper sense of your state of health. Please make sure that the photographs are clear and the camera is level. You're taking an important step today on your journey to wellness and I am here to support you. Looking forward to meeting with you soon!

Name

First NameLast Name

Email

example@example.com

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Age

Date of Birth

Time of birth

Location of birth

Current weight

Current height

Relationship status (married, single, in a relationship). If in a relationship, for how long and how is it going? Do you live together?

What is your occupation? Describe your work schedule/pattern. Are you happy with it?

What do you do for play, enjoyment, and recreation? Hobbies?

What do you do to relax and rejuvenate?

Do you meditate, practice Yoga asana, or pranayama? If so, please describe what you do and the frequency.

Please add anything else you would like to include about your daily life and schedule (patterns, rituals, spiritual practices, spiritual beliefs etc.)

How would you describe your personality?

Are you being treated by any other practitioner(s) at the moment? If yes: What type, how long, the reason, and your progress.

Mother

Father

Grandparents

Siblings

List any symptoms, ailments, or diagnoses you are experiencing at this time. Include the symptoms and duration for each.

List all supplements and medications you are taking, including name, the reason you are taking it, dose and frequency.

Have you had any significant or persistent problems or diagnoses in the past? If so, please list with any current symptoms

Have you had any surgeries, including cosmetic procedures? If so, please list along with the date. Please also include any injections taken in the last 5 years, including vaccines, medical, or cosmetic.

Describe what food and drink you consume.

Describe how you eat, including, when, where, how much, with whom, etc.

How do you experience hunger and how often?

How long does it take to eat your meal on average? Do you chew your food well so that no solids are swallowed?

How many times a day do you eat? How much time do you leave in between eating, whether a meal or snack?

Do you have belching or gas during or after eating? Please describe.

Do you get sleepy right after eating? An hour later? Two hours later?

What kinds of light, dry, cold, or hard food do you eat? (Ex: crackers, bread, ice cream, nuts, salads, etc.) How much and how often?

How often do you eat refined food (including refined sugar)?

How often and what raw food do you eat (including salads)?

How often do you use oil or ghee in your cooking? Which oils do you use and approximately how much per meal?

Do you eat deep fried food? How often?

Are you vegetarian or vegan? If yes to either, how long?

How do you feel about what and how you eat?

Describe how your digestion feels. (Ex: erratic, sluggish, fast, balanced, get very thirsty, etc.)

Which is your favorite taste: sweet, salty, sour, bitter, pungent (hot) or astringent?

How much water do you drink? Describe in glasses/day. What is the temperature of the water you drink (iced, cold, room temperature, warm, hot)?

Do you drink or eat caffeine, such as coffee, caffeinated tea, cacao or chocolate?How much and how often?

Do you smoke cigarettes, consume marijuana or drink alcohol? If so, how much and how often?

Do you currently use any mind-altering drugs, or have you in the past? If so, which ones, and how often? (This includes plant medicine)

Which of these do you experience: gas or bloating, heartburn, nausea, bad breath, bleeding gums, ulcers, irritable bowel syndrome, abdominal pain, liver problems, or gallstones?

Do you have food intolerances or allergies? If yes, what?

How many bowel movements per day do you have?

Describe your bowel movements: ease, does it float or sink, any mucous, color, any undigested food present.

Do your bowel movements have odor? If yes, please describe. Is it sometimes or all of the time?

Do you have constipation? If yes, how often do you have a bowel movement? When did this pattern begin?

Do you have diarrhea? If yes, how often?

Do you have hemorrhoids? If yes, do they itch or bleed?

Do you experience any of the following conditions: cystitis, cold sores, nasal drip, thrush, eczema, inflammation, psoriasis, hay fever, candida, migraine, irritable bowel, asthma, other (if other, please describe)?

Do you feel you have strong immunity?

How many colds/flus or illness do you experience per year?

Do you breathe deeply and easily?

How many times a day do you urinate?

What is the color? (cloudy, red, yellow, pale yellow, clear)

Does your urine have odor? If yes, describe. Is it sometimes or all of the time?

Do you urinate during the night? If yes, how many times?

Do you experience any of the following: water retention, interstitial cystitis, painful urination, frequent urination, blood in urine, urgency of urination, kidney/bladder stones, burning urine, decrease in flow, prostate enlargement, irregular flow, difficulty stopping or starting, inability to hold urine?

Do any of these apply to you: erratic energy, night sweats, frequent fevers, chronic fatigue, slow metabolism, chills, sudden energy drops, generally feeling tired, recent weight gain, recent weight loss, excessive thirst, grogginess in the mornings?

Do you sweat? Easily? How often?

Does the sweat have odor? If so, is sometimes or all of the time?

Do you feel hot, cold or neutral inside? Do you feel hot, cold or neutral on the outside of your body?

Is your skin particularly sensitive? If so, describe how.

Describe your energy levels throughout the day (morning, midday, afternoon, evening)

Yourself:

Finances:

Sex and Intimacy:

Family:

Life purpose:

Spouse/partner:

Do you allow yourself to experience your emotions? Do you express them easily?

Is there an excess of stress in your life? If yes, what is the cause? Do you feel like you have people close to you that you can be vulnerable with about what might be going on in your life?

Do you have tools or techniques to relieve stress? If yes, what are they?

Have there been any significant changes or large stressors in your life now or in the recent past? How do you feel about them?

Are you satisfied with your current living and working environments?

If there is one thing in your life that you would like to change right now, what is it?

Do you experience anxiety, fear, or nervousness? If yes, do you know what makes you feel that way?

What feelings do you most often experience in your life? (Ex: joy, happiness, anger, sadness, fear, anxiety, worry, depression, etc.)

How do you respond to fear? (denial, retreat, aggression, hiding, etc.)

How would you describe the state of your mind?

How would you describe your current emotional state?

What is your overall contentment with your life on a scale of 0 to 10?

Part 1: Ayurvedic Wellness Questionnaire

Family History

Current Health

Digestion and Eating

Elimination (bowel)

Immunity

Urination

Vitality

Mind and Emotions