BODY TYPE ANDMEDICAL ASSESSMENT
with
Cordelia Gaffar
The Ultimate Joy Goddess, Somatic Healer
Full Name
*
First Name
Last Name
E-mail Address
*
example@example.com
Contact Number
*
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
www.cordeliagaffar.com
Back
Next
BODY TYPE ANDMEDICAL ASSESSMENT
with
Cordelia Gaffar
The Ultimate Joy Goddess, Somatic Healer
Has your doctor ever said your blood pressure was too high or too low?
Please Select
Yes
No
Please provide details.
Do you have any known cardiovascular problems (abnormal ECG, previous heart attack, etc)?
Please Select
Yes
No
Has your doctor ever told you that your cholesterol was too high?
Please Select
Yes
No
Have you (or a family member) ever been told that you have diabetes?
Please Select
Yes
No
Do you have any injuries or orthopedic problems (back, knees, etc)?
Please Select
Yes
No
Do you have stiff or swollen joints?
Please Select
Yes
No
Do you have tension or soreness in any area?
Please Select
Yes
No
Are you taking any prescribed medications or dietary supplementation?
Please Select
Yes
No
Do you ever have problems sleeping?
Please Select
Yes
No
Are you pregnant or post-partum (<6 weeks)?
Please Select
Yes
No
Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise/activity?
Please Select
Yes
No
Do you have any other medical condition, injury or anything else we should be aware of that we have not mentioned?
Please Select
Yes
No
www.cordeliagaffar.com
Back
Next
BODY TYPE ANDMEDICAL ASSESSMENT
with
Cordelia Gaffar
The Ultimate Joy Goddess, Somatic Healer
This portion of the form is to assess your body type according to your innate temperament.
"Let your food be your medicine...It is more important to know what sort of person has a
disease than to know what sort of disease a person has." " Hippocrates.
In traditional Islamic Medicine doctors first assessed one's body type:
Sanguine - People Oriented
Phlegmatic - Service Oriented
Melancholic - Quality Oriented
Choleric - Results Oriented
These body types do have groupings and you can be a combination.
Before offering treatment there were six lifestyle areas taken into account and also became an
added prescription:
Air Quality/ environment
Rest and sleep cycle
Active and physical cycle
Emotional
Food
Elimination
The goal of this assessment is to determine your body type so that you can prescribe a new
lifestyle direction.We each fall into one of four categories for a body type or temperament. In
this assessment, I ask you questions that will help you better understand how to feed your body.
Once you have completed the form, schedule a call with me here.
https://calendly.com/theultimatejoygoddess/aftercare-meeting
www.cordeliagaffar.com
Back
Next
BODY TYPE ANDMEDICAL ASSESSMENT
with
Cordelia Gaffar
The Ultimate Joy Goddess, Somatic Healer
Select the complexion which most closely describes you currently, most of the time
Please Select
Red,ruddy,flush
Yellow
Dusky,dark
White, chalky, pale
What is your build?
Please Select
Heavy, with joints well developed
Lean, medium
Lean, thin
Flabbiness, laxity of joints
How do your eyes look?
Please Select
Red, tinge
Yellow, tinge
Dull, piercing
White type
How does your tongue look?
Please Select
Red
Dry, yellow
Dark
White
What taste do you naturally have in your mouth without any other influences (i.e. without food and drink)
Please Select
Sweet
Dry
Bitter, methalic
Moist
What is your general level of thirst?
Please Select
Excessive
Excessive with dryness
Lack of thirst with dryness
Lack of thirst
How is your appetite and digestion?
Please Select
Good appetite, quick digestion
Good appetite, strong digestion
Moderate appetite, poor digestion
Weak appetite, weak digestion
How is your sleep?
Please Select
Moderate sleep
Less sleep
Poor sleep
Increased sleep
www.cordeliagaffar.com
Back
Next
BODY TYPE ANDMEDICAL ASSESSMENT
with
Cordelia Gaffar
The Ultimate Joy Goddess, Somatic Healer
How are your sense perceptions?
Please Select
Active
Acute
Anxiety
Dullness
Slow
How are your bodily excretions?
Please Select
Prone to bleeding e.g. nosebleeds, gums
Prone to diarrhea and high color urine
Prone to excretions with strong odors and thin urine
Prone to thin urine and thick saliva
What do you tend to dream about?
Please Select
Blood, red item
Fire, yellow
Dark objects, fearful places
Water, rain, cold, snow, rivers
How's your skin?
Please Select
Prone to pimples and boils
Dry, yellow tinge
Dry, rough
Cold moist and whitish
How's your pulse?
Please Select
Full
Rapid,thin
Weak
Soft, slow
What makes you feel better?
Please Select
Yawning and stretching
Cold, moisture
Warmth
Heat
At what time do you feel worse?
Please Select
3 am to 9 am
9 am to 3 pm
3 pm to 9 pm
9 pm to 3 am
How is your hair?
Please Select
Thick, luxuriant
Curly
Less hair, darker
Lighter color, thinner
www.cordeliagaffar.com
Preview PDF
Submit
Should be Empty: