Wellness Questionnaire
Please take time to answer this questionnaire, it is vital for a proper Ayurveda assessment.
Select an option from each list
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11%
Personal Details
Name
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First
Last
Age
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Weight
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Hight
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Date of birth
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MM slash DD slash YYYY
Relationship status
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Occupation
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Email
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Phone
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Health
Date of last check-up: Medications being taken.
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Health Problems (past & current)
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Health problems in your family
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Do you take any supplements, medications, or herbs? List all supplements and medications you are taking. For each, specify name, the reason you are taking it, dose and frequency.
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How long have you been taking it?
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What differences have you noticed from the beginning and recently in taking them ?
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The problem you experienced is solved, or has it returned?
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Someone recommended or prescribed supplements or medications? Or was it self-prescribed?
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Do you take any supplements, medications, or herbs? List all supplements and medications you are taking. For each, specify name, the reason you are taking it, dose and frequency
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How long have you been taking it?
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What differences have you noticed from the beginning and recently in taking them ?
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Someone recommended or prescribed supplements or medications? Or was it self-prescribed?
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Please specify any allergies and intolerance for food.
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How it is your digestion? How many times during the day you go to the toilet? Specify quality of your bowel movements. Do you experience any bloating, inflammation, heartburn, gas, frequent burping, sluggish digestion, cramping/pain)?
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Do your bowel movements have odor? If yes, please describe. Is it sometimes or all of the time?
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Do you have diarrhea? If yes, how often?
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Do you have hemorrhoids? If yes, do they itch or bleed?
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Urine. Please specify color and how many times you go to the toilet?
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Menstrual Cycle. Please specify length, flow, timing and how is the texture of the blood.
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Sweat. Sweating is a natural process that helps regulate your body temperature and cool you down when you’re hot or exerting yourself. Please specify how it is your sweat.
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Do you usually feel cold, or warm in your body, or both?
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Do you feel you have strong immunity?
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How many colds/flus or illness do you get per year?
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Do you experience any symptoms such as cramping, numbness or tingling in the hands and feet, swelling around joints, memory loss or difficulty concentrating, fainting, digestive issues, fatigue, skin color changes, or varicose veins? If so, please specify.
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Does your skin tend to be dry, oily or moist?
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Is your skin texture thin, medium or thick?
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Any problems with your head, eyes, ears, nose, tongue or throat?
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How it is your sleep habits? Specify your schedule for sleeping.
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Tongue
Upload Video (MP4)
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Please submit a clear video of your tongue: start with the tongue in the mouth, then extend the tongue so we can see the full surface. Make sure to open the mouth & hold the tongue out for at least 3 seconds. Then return the tongue into the mouth.
Accepted file types: mp4, Max. file size: 64 MB.
Upload 3 Images
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Please upload a picture of your full body (front and side views/ right and left side, in form-fitting or Yoga clothes). We 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.
Drop files here or
Select files
Accepted file types: jpg, png, Max. file size: 6 MB, Max. files: 3.
Describe your tongue including color, shape, location and color of coating, marks or crevices. pink color, average shape, no coating, crevice in the middle.
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Diet
Type of food you consumed daily
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Type of drinks you consumed daily
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How do you consume your food? Please specify how many meals during the day you eat . How much time do you leave in between eating, whether a meal or snack?
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How do you drink? Please specify how many drinks you take during the day and the time you drink them.
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Do you chew your food well? About how many chews per bite?
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How often do you eat refined food (including refined sugar)?
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How often and what raw food do you eat (including salads)?
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Do you eat deep fried food? How often?
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Which is your favorite taste: sweet, salty, sour, bitter, pungent (hot) or astringent?
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Do you drink or eat caffeine, such as coffee, caffeinated tea or chocolate?How much and how often?
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Do you smoke cigarettes, consume marijuana or drink alcohol? If so, how much and how often?
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Do you experience gas or bloating, heartburn, nausea, bad breath, bleeding gums, ulcers, irritable bowel syndrome, abdominal pain, liver problems, or gallstones?
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Lifestyle
Do you have a hobby?
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What do you like to do in your free time?
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Do you practice any sport? If you do, how many times during the week do you practice?
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Do you practice Yoga? If you do, how many times during the week do you practice?
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Do you meditate? If you do how many times during the week do you practice?
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Do you practice pranayama? It means breathwork. If you do how many times during the week do you practice?
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What do you usually do for relaxing ?
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What do you usually do for entertainment ?
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Work
Describe your work schedule.
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Do you enjoy your work?
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Is there anything you would like to change in your work?
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How do you feel financially?
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Relationships
If you have an actual partner, describe your relationship. How do you feel about it
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How long have you been together?
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Do you have kids? If so, please specify ages?
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How is your relationship with your kids?
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How is your relationship with your parents?
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How is your relationship with your siblings?
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Emotional and mental state.
How do you feel mentally and emotionally?
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If there is any emotion that triggers you continuously? If yes, please specify what triggered that emotion?
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What is the intensity of this emotion?
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How long have you been feeling this way?
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What is the best way to respond to this emotion?
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What can you do to manage this emotion?
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What can you do to prevent this emotion from recurring?
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If there is one thing in your life that you would like to change right now, what is it?
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Personality
Please describe your personality
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How do you see yourself
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Comments
This field is for validation purposes and should be left unchanged.
