Ayurvedic Consultation Form
Please answer honestly and instinctively. There are no right or wrong answers. Select all options that fit. If you can choose only one, pick what fits you most of the time. This form helps us see your complete health picture—not just your symptoms. Allow 25–30 minutes.
PART 1 — About You
Q1A. Full Name
*
First Name
Last Name
Q1B. Biological sex (assigned at birth)
*
Female
Male
Intersex
Prefer not to say
Q1C. Age, Height, Weight
*
Q1D. E-Mail/ Contact
*
E-Mail
Contact Number
Q1E. Occupation & Location
Q1F. Work or environment-related exposures (select ALL that apply)
*
Primarily standing or physical work for most of the day
Irregular or unpredictable daily routine — shift work, caregiving, frequent travel, or no fixed schedule
Frequent long-distance travel or regular long drives
Rarely get natural daylight within the first hour of waking — indoor morning routine most days
Desk or computer work — seated for most of the day
Screen time more than 6 hours per day
Dust, fumes, or chemicals
Heavy metals or pesticides
Noise or vibration
Other
PART 2 — Your Main Health Concern
Q2A. Describe your main health concern in your own words — include when it started, suddenly or slowly, and how it has changed since
*
Q2B. Other symptoms that appeared together with your main problem — not ones you had earlier
Q2C. Compared to 3–5 years ago, your overall health is
Much better
Somewhat better
About the same
Somewhat worse
Much worse
Q2D. Which of these appeared BEFORE your main complaint?
Unexplained fatigue, heaviness, or loss of enthusiasm
Digestive changes — bloating, irregular appetite, or altered bowel
Sleep disturbance, restlessness, or mood shift
Skin changes, itching, or unusual body odour
Joint stiffness or body aches
A sensation of something stuck or tight in the throat — not painful, comes and goes
No clear early warning — symptoms appeared suddenly
Other
Q2E. In the 6 -12 months before it started, did any of these life events occur?
Major emotional loss, conflict, or shock
Significant change in diet, sleep, or work schedule
Surgery, serious illness, or long antibiotic or steroid course
Pregnancy, delivery, or hormonal change
Relocation, migration, or climate change
None of the above
Other
Q2F. Your main complaint clearly worsens with
*
Stress or emotional upset
Physical exertion
Cold weather or cold exposure
Heat or hot weather
A specific season
Wind or dry air
Damp or humid weather
Empty stomach or delayed meals
Eating — regardless of which food
Lack of sleep
Generally feel colder than others in the same environment — cold hands, feet, or body most of the time
Generally feel warmer than others — prefer cool air, throw off covers, warm palms or soles in the evening
Specific posture or position
Other
Q2G. Your main complaint clearly improves with
*
Rest
Gentle movement or exercise
Heat application
Cold application
Eating
Pressure or massage
Fresh air
None — nothing helps
Other
Q2H. Does it follow a pattern — time of day or season?
*
Worse in morning
Worse in afternoon
Worse in evening or night
Worse in certain season
No clear pattern
Other
Q2I. Have any specific herbs, home remedies, or medicines helped noticeably — which and how quickly?
Q2J. Do you feel your current health problem is primarily driven by:
Physical causes — diet lifestyle infection or injury
Emotional or mental causes — stress, grief, fear, trauma, or unresolved conflict
Both physical and emotional equally
No clear cause found despite looking
Other
PART 3 — Digestion & Food
Q3A. Which foods reliably cause discomfort?
Dairy — milk, cheese, yogurt
Wheat or gluten
Beans, lentils, legumes
Fried or oily foods
Raw vegetables or salads
Cold or iced foods or drinks
Spicy foods
Sweets or sugary foods
Meat or heavy proteins
Fermented foods
Nightshades — tomatoes, peppers, aubergine, potatoes etc.
FODMAP foods — e.g. onion, garlic, wheat, certain fruits etc.
Any meal causes heaviness or discomfort — not specific to one food
None of the above
I tolerate all foods well
Other
Q3B. Eating schedule and food habits (select what applies most of the time)
Eat at regular times daily
Often eat late at night within 2 hours of sleep
Eat when convenient, not at fixed times
Eat quickly or while distracted
Daily meals include cold, packaged, fried, or processed foods
Rarely eat home-cooked fresh food
Eat again within 1–2 hours of a previous meal — snacking before the last meal feels digested
Q3C. Your appetite right now — over the past month
*
Strong and regular — hungry at mealtimes each time
Variable — some meals hungry others no appetite
Weak or absent — rarely feel hungry have to remind yourself to eat
Excessive — unusually strong hunger never fully satisfied
Fluctuating — sudden intense hunger then no appetite at all
Other
Q3D. How do you usually drink water or fluids? (select the one that you do most)
I drink warm or room-temperature water, sitting down, in small sips, mostly when thirsty
I drink cold or iced drinks regularly, often during or right after meals
I drink standing up, quickly, in large gulps — often from a bottle on the go
I rarely feel thirsty or often forget to drink — probably drink too little
I drink large amounts constantly — always carrying water, drink far more than others
I drink large amounts during meals as a habit
I drink during meals because my mouth or throat feels dry
I often feel thirsty but have little desire to actually drink — or I want only a few small sips and feel satisfied
Q3E. Typical Daily Meals
*
Rows
regular food items
time
Portion
Temperature
Breakfast
Small
Medium
Large
Cold
Warm
Lunch
Small
Medium
Large
Cold
Warm
Dinner
Small
Medium
Large
Cold
Warm
Snacks
Small
Medium
Large
Cold
Warm
Q3F. Incompatible food combinations you regularly eat (select all that apply)
Honey heated or cooked
Milk with sour fruits
Yogurt at night or heated
Milk with banana
Fruit immediately after meals
Melons eaten with or after any other food
Ice-cold drinks with hot food
Milk with salt or salty foods
Radish with milk or fish
Beans/Legumes with dairy
Eating within 2–3 hours of previous meal before it is digested
Eggs with milk or dairy
Yogurt with hot food or hot drinks alongside it
None of the above
Q3G. For any combination you tick — how often do you consume it?
Rarely (once a month or less)
Sometimes (a few times a month)
Often (1–3 times a week)
Daily
PART 4 — Tongue, Morning Signs & Toxin Build-up (Āma)
Q4A. On waking what do you notice about your tongue and mouth? (select all that apply)
*
Thin white coating
Thick white or grey coating
Yellow or greenish coating
Clean pink with no coating
Tongue appears red or inflamed
Tongue appears pale
Scalloped/wavy edges or tooth marks on sides
Cracks, grooves, or deep lines on the tongue surface
Metallic, bitter, or unusual chemical taste on waking
Mouth ulcers or bleeding gums
None of the above
Q4B. Āma (Toxin) Accumulation Indicators
*
Rows
Not at all
Mild
Moderate
Severe
Heaviness in body or limbs
Digestion feels slow, stuck, or blocked
Bad breath or foul body/sweat odour despite hygiene
Stool feels sticky, pasty, or coats the bowl
Lack of clarity or foggy mind
Food still feels heavy, full, or undigested more than 2 hours after eating
Face, hands, or feet look or feel puffy when you wake up
Blocked sinuses, ears, or persistent nasal congestion
Pain or discomfort that moves, wanders, or shifts — no fixed location
Pain or discomfort that is fixed, dull, heavy, or pressing — stays in one area
PART 5 — Elimination & Body Outputs
Q5A. Stool frequency and evacuation pattern
*
Daily, effortless, feels complete within 5–10 minutes
Daily but takes effort, straining, or more than 15 minutes
Daily but feels incomplete — like something is left inside
Every 2–3 days
Less than every 3 days
More than once daily — loose or urgent
Very irregular — no pattern
Q5B. Stool consistency/form (answer from how it felt or looked)
*
Dry & effortful — pellets or pieces, scratchy, needs straining
Formed but resistant — solid, rough surface, needs pushing, incomplete feeling
Smooth & complete — one easy pass, clean, no residue, feels done
Soft & shapeless — breaks apart, multiple wipes, strong smell
Loose or urgent — mostly liquid, burning, hard to hold
Thin, ribbon-like, or pencil-width — flat strip regardless of frequency
Unpredictable — alternates between hard and loose with no clear pattern
Q5C. Any of the following with stool? — select all that apply
Visible mucus — mucus you can clearly see separate from stool
Undigested food particles
Floating or greasy stools
Bright red blood on paper or in bowl
Bleeding, itching, or swelling around anal area
Foul or unusually strong odour
Pale, grey, or clay-coloured stool — not dark or yellow-brown
None of the above
Q5D. What is your sweating pattern — select all that apply
Normal sweating with exertion
Excessive sweating even at rest or minimal effort
Very little or no sweating even during exercise or heat
Night sweats without fever
Odour noticeably strong even with good hygiene
No concerns — sweating feels appropriate for my activity level
Q5E. Urination — typical daytime and night-time frequency
*
3-4 times daily no night waking
5-6 times daily night once
7 or more times daily, night 2-3 times
Very frequent day and night 3 or more times at night
Q5F. Urine colour most of the time
Clear or very pale
Light yellow
Dark yellow or amber
Orange or deep yellow-orange
Reddish, pink, or visible blood
Cloudy or foamy
Q5G. Urinary discomfort or changes — select all that apply
Burning sensation during urination
Difficulty starting to urinate — have to wait or push
Urine flow is weak, slow, or keeps stopping and starting
Sudden urgent need to urinate — hard to hold
Incontinence or leakage
None of the above
Q5H. Do you often suppress or hold natural urges? — select all that apply
*
Stool
Urine
Belching or passing gas
Sneezing
Yawning
Tears or crying
Vomiting when nauseated
Hunger — delay meals despite hunger
Thirst
Sleep — stay awake despite sleepiness
Pushing through physical effort even if the body feels tired or exhausted
None — I respond to urges naturally
PART 6 — Sleep, Dreams & Daily Rhythm
Q6A. Usual bedtime most nights
*
Before 10 PM
10 to 11 PM
11 PM to midnight
After midnight
Very irregular — no fixed time
Q6B. How long does it usually take to fall asleep?
*
Under 15 minutes
15-30 minutes
30-60 minutes
More than 1 hour
Fall asleep easily but wake and cannot return to sleep
Q6C. If you wake during the night which pattern fits? (select all that apply)
*
Wake 10 PM–2 AM with heat, heartburn, hunger, or irritability
Wake 2–4 AM with racing thoughts, worry, or restlessness — no clear reason
Wake 4–6 AM, sleep becomes very light or you feel fully awake and cannot return to sleep
Wake 6–8 AM with heaviness, nausea, or very slow to start
Wake at random times multiple times no fixed pattern
Do not wake — sleep through the night
Q6D. Total sleep duration most nights
Less than 5 hours
5-6 hours
6-7 hours
7-9 hours
More than 9 hours
Q6E. On waking, I also typically notice (select all that apply)
Dry mouth, dry lips, or sore throat on waking — whether from thirst or mouth breathing during sleep
Strong thirst
Excess saliva or sour taste in mouth on waking
Nausea or sour-acid taste in mouth
Heaviness in head or body
Headache on waking
None of the above
Q6F. Most frequent dream type over the past 3 months
Peaceful, pleasant, nature, or light scenes
Flying, falling, chasing, running — unable to reach destination
Fire, arguments, violence, or intense heat
Water, floods, drowning, or swimming
Fear, darkness, trapped, unable to move or scream
Repetitive same dream for months, or deceased relatives appearing
Sexual or intensely romantic dreams
Rarely dream or cannot recall dreams
Other
Q6G. Tick only if the dream REPEATS regularly — not something that happened just once
Teeth falling out or body parts detaching
Being attacked or eaten by dark animals or birds
Swallowing fire or burning from inside
House in ruins or city collapsing
None of the above
Q6H. How active are you, and when?
Rows
Morning before 10 AM
Midday 10 AM to 2 PM
Evening 4 PM to 7 PM
Night after 7 PM
Timing varies
Not applicable
Sedentary — little or no deliberate exercise
Light — walking yoga or stretching under 30 min per day
Moderate — brisk walk cycling or swimming 30-60 min 3-5 times per week
Intense — gym HIIT running or sport 5 or more times per week
PART 7 — Energy & Vitality
Q7A. Energy through the day
Stable and consistent
Mind feels switched on and restless even though the body is exhausted — hard to relax even when tired
Crashes at specific times — morning, afternoon, or evening
Low in the morning regardless of how much sleep I get — only feel functional after caffeine or 1–2 hours of being awake, but energy improves through the day
Mostly low throughout
Q7B. When you rest properly on a weekend or vacation, do you
Feel genuinely restored
Feel somewhat better but still tired
Still feel drained — rest does not help much
Feel worse or more sluggish after rest
Q7C. Vitality (Ojas) Assessment
*
Rows
Not at all
Mild
Moderate
Severe
Do you catch colds, infections, or fall sick easily
Do you experience deep fatigue that does not improve with rest
Do you feel emotionally fragile — easily upset, overwhelmed, or unable to feel steady inside
Do you feel empty, flat, or unable to feel satisfied — even when nothing is obviously wrong
PART 8 — Stress, Emotions & Mind
Q8A. How do you typically cope when stressed? (select all that apply)
*
Overworking or staying busy
Withdrawing or avoiding people
Overeating or comfort eating
Loss of appetite
Smoking
Drinking alcohol
Excessive screen time — scrolling or series-watching
Irritability or arguments
Exercise or physical outlet
Talking to friends or support network
Meditation, prayer, breathwork, or a spiritual practice
Other
Q8B. Which of the following describe your mental-emotional state most of the time over the past 6–12 months? (select all that apply)
*
Persistent worry, overthinking, or racing mind — hard to switch off
Sadness, low mood, or loss of interest in things I used to enjoy
Irritability, sudden anger, or reacting more strongly than intended
Emotional numbness flatness or feeling disconnected from life
Anxiety or sudden fear — racing heart or breathlessness without clear reason
Holding on to resentment, difficulty forgiving, or a strong feeling that something was deeply unfair
Mood swings with no clear trigger
Feeling overwhelmed or unable to cope with ordinary demands
Persistent unresolved conflict — feeling stuck in a situation or relationship
Calm and stable — no significant emotional concerns
Q8C. The emotional pattern that feels like your natural character — how people who know you well would describe you on a calm, ordinary day, not during a difficult period:
*
Restless and vigilant — easily startled, mind rarely settles, unnamed anxiety, feel unsafe without clear reason, difficulty trusting situations or people
Intense and reactive — strong inner critic quick to frustration sense of injustice hard to release high standards for self and others
Heavy and withdrawn — slow to initiate, drawn to comfort, low mood not lifted by good events, carry the past, seek food or sleep for solace
Balanced — none of the above consistently
Q8D. Which of the following have affected you significantly at any point in your life? (select all that apply)
Loss of a close person — death abandonment or sudden separation
Childhood home felt unsafe cold chaotic or unpredictable
Violence abuse or persistent humiliation
Chronic emotional neglect — felt invisible unheard or unwanted
Major betrayal of trust — in relationships family or work
Prolonged financial occupational or social insecurity
Serious illness medical trauma surgery or chronic physical suffering
Forced uprooting — migration displacement or loss of community
Identity-related harm — discrimination rejection or deep shame
None of the above
Q8E. Overall how much do these past experiences still affect your sleep, mood, body symptoms, relationships, or sense of safety today?
Fully resolved — no longer affects me
Occasionally surfaces — mild and manageable
Still affects me regularly — mood body or behaviour
Feels largely unresolved — significantly shapes my daily experience
Prefer not to say
Q8F. On an ordinary day — not during stress — your inner life is most often:
Constantly busy — my mind rarely settles into genuine quiet or stillness
Occasionally quiet or content, but easily disrupted — no consistent inner anchor
Supported by a regular practice — meditation, breathwork, reflection, or nature — that gives me real steadiness
Naturally settled and at ease — I feel grounded and inwardly satisfied without needing a formal practice
Purposeful and fulfilled — I have a clear sense of meaning and feel genuinely satisfied with my life, even when things are hard
Other
PART 9 — Body Systems and Red Flags
Q9A. Have you noticed any of the following — if new or unexplained (select all that apply)
*
Chest tightness, pressure, or pain during exertion or stress
Discomfort spreading to left/right arm, jaw, or upper back
Chronic cough, wheeze, or breathlessness on mild effort
Persistent pressure headaches, dizziness, or brief one-sided weakness
Sudden slurring, difficulty finding words, or one-sided facial drooping
Blurred vision or sudden visual disturbance
Foamy or cloudy urine, persistent pain in the side or lower back, or swelling in legs or ankles
Unexplained weight loss, a lump, or a sore not healing in 3 weeks
Excessive thirst and slow wound healing
Ringing in ears or tinnitus, muffling, or reduced sharpness in hearing
Gradual blurring, difficulty with fine detail, or increased sensitivity to light
Reduced sense of smell or taste — foods taste flat or different than before
Persistent or unexplained tingling, numbness, or burning — in hands, feet, skin patches, or fingertips
Headache, nausea, or fatigue after small amounts of alcohol, caffeine, or brief exposure to strong smells — perfumes, paint, exhaust
None of the above
Other
Q9B. How has your weight changed in the last 6–12 months without intentional diet change?
Stable
Gained noticeably
Lost noticeably
Fluctuating unpredictably
Q9C. Skin concerns — select all that apply
Very dry, rough, or cracked
Oily or greasy
Rashes, eczema, or itching
Acne or breakouts
Discolouration or dark patches
Sensitive or reactive skin
None
Q9D. If morning stiffness — how long until it eases after getting up?
Not applicable — I do not have joint concerns
Under 30 minutes
30–60 minutes
More than 1 hour
Does not ease until mid-day or later
PART 10 — Medical History & Medications
Q10A. Diagnosed conditions — past or current (select all that apply)
*
Diabetes or pre-diabetes
Hypertension
Thyroid disorder
Asthma or respiratory condition
Heart disease
Arthritis or joint disorder
Autoimmune disorder
Digestive disorder — IBS, IBD, GERD, Crohn's
Neurological disorder
Kidney disorder
Cancer — past or current
Mental health diagnosis
Other
None
Q10B. Past surgeries or major procedures with approximate dates
Q10C. Hospitalisations or serious infections with approximate dates
Q10D. List your vaccination history — COVID-19, Influenza, others. Note any reactions or health changes after vaccination.
Q10E. In the past 6 months, did any of the following noticeably change your health? (infection, antibiotic course, steroid use, surgery, or vaccine)
No
Yes — please describe what happened and what changed below
Describe what happened and how your health changed
Q10F. After any previous major illness surgery or significant stress did your health fully recover?
Yes — fully recovered each time
Partially — never quite back to baseline
No — health declined from a specific point and never returned
Not applicable
Q10G. Ongoing medications/supplements/herbs etc. Timing: e.g., empty stomach / before meal / after meal / before bed / random
Rows
Medicine/Supplements
Dosage, mg etc.
Per Day
Timing
Since when
1
Once
Twice
Thrice
2
Once
Twice
Thrice
3
Once
Twice
Thrice
4
Once
Twice
Thrice
5
Once
Twice
Thrice
6
Once
Twice
Thrice
7
Once
Twice
Thrice
Q10H. Any long courses of (select all that apply)
*
Oral contraceptives or hormonal birth control
Regular painkillers or anti-inflammatories NSAIDs
Antacids or acid-reducing medicines such as omeprazole or pantoprazole
Antibiotics
Hormonal therapy — HRT, testosterone, thyroid
Psychiatric medicines — antidepressants, sedatives, anti-anxiety drugs
Long-term laxatives or stool softeners
Corticosteroids
Immunosuppressants for autoimmune or transplant
Chemotherapy or radiotherapy
None of the above
Other
Q10I. Laboratory tests or scans done for your current problem — can bring reports to consultation
Q10J. Substance and stimulant use — for each row, select the option that fits you best
Rows
Never
Occasionally or socially
Weekly
Daily — low or moderate amount
Daily — high amount or feel I cannot easily stop
Cigarettes, vaping, or tobacco
Alcohol
Tea, coffee, or caffeinated drinks (green tea, matcha, mate, energy drinks)
Recreational drugs (cannabis, stimulants, or others)
PART 11 — Background & Previous Treatments
Q11A. Overall, how helpful were previous natural or traditional treatments?
Significantly helpful — clear improvement
Partially helpful — some benefit but incomplete
Neutral — no noticeable effect
Made things worse
Too early to judge / did not complete the course
Have not tried any
Q11B. For any treatment ticked above — describe: what condition it was for, how long you tried it, and whether it helped, was neutral, or caused issues?
Q11C. Strong health patterns in your family — parents, siblings, grandparents — select all that apply
Metabolic & hormonal — diabetes, obesity, thyroid, or hormonal disorder
Heart, blood pressure, or circulation
Digestive — IBS, IBD, Crohn's, ulcers, or chronic gut complaints
Joints, bones, or autoimmune — arthritis, lupus, inflammatory or immune disorder
Cancer — digestive, hormonal, blood, or other
Mental health, addiction, or chronic fatigue — anxiety, depression, burnout, or low stamina
Kidney, urinary, or reproductive disorder
Neurological — migraines, epilepsy, neuropathy, or tremors
Strong family tendency to be very lean or to gain weight easily
A complaint very similar to my current one
None known
Other
Who in your family, and what complaint?
PART 12 — Reproductive and Hormonal Health
Q12A. Current reproductive status
*
Not pregnant and not breastfeeding
Currently pregnant
Currently breastfeeding
Not applicable
Q12B. Menstrual status — select one
Regular periods — no notable change
Periods present but clearly changing in length, flow, timing, or skipping
Likely perimenopause — noticeable changes in periods, mood, hot flashes, or sleep lasting more than a year
No period for 12 or more months — natural menopause
Cycles stopped due to surgery, medication, or hormone therapy
Not applicable
Q12C. Menstrual and hormonal details (select all that apply)
Heavy flow or prolonged bleeding more than 6 days
Very scanty or light flow
Significant pain or cramping
Large or frequent clots
Dark brown or very pale pink colour
Hot flashes or night sweats
Skipped one or more periods in past year
PMS — bloating or water retention
PMS — irritability, anger, or mood swings
PMS — low mood, tearfulness, or withdrawal
PMS — breast tenderness
PMS - strong food cravings
Vaginal dryness or joint aches — since periods changed or stopped
None of the above
Q12D. Reproductive history — pregnancies, deliveries, miscarriages, fertility treatments, postpartum complications, PCOS, endometriosis, fibroids, discharge. Describe any relevant concerns.
Q12E. Men — Prostate, Urinary Tract and Sexual Function (select all that apply)
Difficulty starting to urinate or weak urine flow
Urinating at night 2 or more times
Feeling of incomplete bladder emptying after urinating
Pain or burning in the prostate area or during urination
Reduced libido or declining interest in sex — no clear reason
Erectile dysfunction or changes in sexual performance
These symptoms began after taking steroids, hormones or testosterone
None of the above
PART 13 — Your Goals and Readiness
Q13A. What would successful treatment look like for you specifically? — symptom relief, energy, mental clarity, sleep, function
Q13B. What feels too hard or unrealistic to change right now?
Q13C. How would you describe your motivation to change right now?
*
I am not ready — managing as I am for now
I am thinking about it — but not ready to act yet
I want to change but feel overwhelmed or unsure where to start
I am ready and willing — just need guidance and a clear plan
I am highly motivated — I will follow whatever is recommended
I already started making changes on my own
Q13D. Which lifestyle changes feel realistic for you to try in the next 3 months?
Changing food choices or eliminating certain foods
Improving sleep routine
Adjusting meal times or eating schedule
Adding regular physical activity and its timing
Reducing stress or workload
Addressing emotional or mental health
Taking herbal medicines or supplements
A regular stillness practice — meditation, breathwork, yoga, prayer, Tai Chi, or quiet time in nature
A regular creative or expressive practice — singing, music, art, writing, dance, gardening, or any activity that absorbs you completely
Reducing digital/sensory stimulation — deliberate offline or screen-free periods during the day
Not ready for any changes at this time
Submit
Should be Empty: