Ayurveda Health

Consultation Form

Required fields are marked with *.

Your details

First name: *
Surname: *
Phone number: *
Email address:
Street address: *
Suburb:
City: *
Post code: *

Reason for Consultation

What is the main reason for the consultation. ie What issues would you like to focus on?

Reason for visit:

Questionnaire

Please tick the boxes below which best describe aspects of your body and lifestyle. We are not looking at how you are now but rather what you have been like most of your life. You may tick more than one box in each row if you fall into more than one category.


Body frame	Slim	Medium	Large
Weight	Low, hard to gain	Medium	Overweight, gain easily
Chin	Thin, angular	Tapering	Round, double
Cheeks	Wrinkled, sunken	Smooth, flat	Round, plump
Eyes	Small, dry, quick, black, brown	Gray, green, hazel, blue, light-sensitive, intense gaze	Large, calm, attractive, kind
Whites of eyes	Bluish or brown	Yellow or red	White and glossy
Nose	Uneven, deviated septum	Long, pointed, red tip	Short, rounded, button nose
Lips	Dry, cracked, black or brown tinge	Red or yellowish, inflamed	Smooth, oily, pale, whitish
Teeth	Crooked, big, thin gums	Medium, soft, yellow, tender gums	Healthy, large, white, strong gums
Skin	Thin, dry, rough, dark	Smooth, oily, fair, rosy, freckled, sunburn easily	Thick, oily, white, pale
Hair	Dry, brown, black, knotted, brittle, breaks easily	Straight, oily, blond, red, grey, thinning, bald	Thick, oily, curly, wavy, luxuriant
Nails	Dry, rough, brittle, break easily	Sharp, flexible, pink, lustrous	Thick, oily, smooth, polished
Neck	Thin, long	Medium	Large, folds
Chest	Small	Moderate	Expanded, round
Abdomen	Thin, hard, sensitive	Muscular	Big, thick, soft
Navel	Small, irregular, herniated	Oval, superficial	Big, deep round, stretched
Hips	Slender, thin	Medium	Large, heavy
Joints	Small, cracking	Medium	Large, lubricated
Tendons & Veins	Prominent	Medium	Hidden
Perspiration	Less	More	Average
Temperature	Cold extremities	Warm	Cool, Moist
Menses	Spotty, irregular, cramps	Intense, heavy	Strong, regular
Sex drive	Low, variable	Passionate	Strong, steady
Appetite	Irregular, scant	Strong, unbearable	Slow, steady
Digestion	Irregular, gassy	Fast, acidic, burning	Slow, mucous
Thirst	Changeable	Excessive	Low
Elimination	Hard, dry, constipation	Loose, soft, many, diarrhea if stressed	Thick, oily, sluggish; regular
Strength	Poor	Good	Excellent
Physical activity	Hyperactive	Moderate	Slow
Exercise tolerance	Low, but loves	Medium, may overdo	High, but doesn’t like
Walk	Fast, forestrikes	Average, heel strikes	Slow, pronates
Weather	Aversion to cold	Aversion to hot	Aversion to cool and damp
Mental Activity	Hyperactive	Moderate, sharp	Slow, dull
Emotions under stress	Anxious, fearful, uncertain	Irritable, impatient, angry, jealous	Calm, greedy, clinging
Financial tendency	Spends on trifles	Spends on luxuries	Saves, accumulates wealth
Faith	Variable	Very important	Consistent
Intellect	Quick but can be faulty	Moderate, accurate	Slow, exact
Memory	Recent good, long-term poor	Moderate	Slow to learn, long- term excellent
Voice	High-pitched, fast	Medium pitch, clear	Low pitch, deep, resonant
Moods	Change quickly	Slowly changing	Steady, non-changing
Dreams	Many, quick, active, frightening	Violent, fiery	Watery, romantic
Sleep	Light, interrupted, insomnia	Short but sound	Deep, prolonged

Theme by Dr. Radut.

Ayurveda Health

Consultation Form

Primary links

Newsletter

Shopping cart