Ayurvedic Initial Consultation Form

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Ayurvedic Intake

Personal Info

First Name

Last Name

Phone/Mobile

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Date of Birth

Sex

Male

Female

Other

Marital Status

Married

Single

Divorced

Widow

Widower

Age

Weight

Height

How did you hear about us?

Objectives & History

Please check the items that reflect your main Objectives:

I want an alternative approach to for managing illness and disease

I want to improve my general health and wellness and reduce my vulnerability to illness and disease

I want to improve my lifestyle and dietary practices to improve my health

I want to change my habits and behavioral patterns to improve my relationships with others

I want to manage stress, tension and worry to attain a more stable emotional nature

Current General Health Concerns

Any past history of the following:

Stress related to serious injuries

Trauma / Fatigue or both

Emotional/Mental stresses / Mental Clarity/Concentration

Troubled lifestyle conditions

Vision problems, including dry eyes

Changes in weight

Hot flashes

Aches, pains

Cosmetic surgery

Current Symptoms- please describe

Appetite:

Bowel movement: (be specific e.g. regularity, hard, soft, color etc)

Sleep issues and quality

Urine: color- flow- how many times a day-

Stress level (Be specific about how it’s affecting your daily life):

Previous Health/Family History.

MALES- current prostate health or provide any concerns you may have.

FEMALES: Menopause: Please describe if you have any pre/post menopausal symptoms

FEMALES: Menstrual Cycle/ please describe any symptoms of concern

Current Medications, Herbs or Supplements What medications are you currently taking or have taken recently, including birth control and hormone replacement therapy?

Vata, Pitta or Kapha

The following simple test will give you a fairly good idea of the levels of your doshas. We have to remember that everyone has all three doshas, but in varying degrees. After reading each description, mark 0 to 7 in the box provided.

Please rate each question according to the following scale and fill in your scores below.

0-1	1-2	3 – 4	5	6 – 7
Does not Apply	Applies Rarely	Applies Sometimes	Applies Often	Applies Most of the Time

Evaluating my Vata Dosha

In Ayurveda Vata dosha is associated with air and space element.

My physique is thin – I don't gain weight easily.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I am quick and active.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

My skin is usually dry, more so in winter.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

My hands and feet are usually cold.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

My energy fluctuates and comes in bursts.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I usually develop gas or constipation.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I usually have difficulty falling asleep or having a sound night's sleep.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I am uncomfortable in cold weather.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

My nature is lively and enthusiastic.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I have difficulty memorizing things and remembering them later.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

It is easy for me to learn new things quickly, but I also forget quickly.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I am not good at making decisions.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I am anxious or worrisome by nature.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

People think I'm talkative and that I talk quickly

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I am usually emotional by nature and my moods fluctuate.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

My mind is restless, but also imaginative.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I have irregular eating and sleeping habits.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

Your Total Vata!

Evaluating my Pitta Dosha

In Ayurveda Pitta dosha is associated with fire & water elements.

My hair is fine, straight, light, blonde, red, graying early, or balding.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I don't tolerate hot weather.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I sweat easily.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

Your body temperature tends to be consistently warm or hot.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

My appetite is very good and I can eat big meals.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

You do not view eating as a particularly productive activity, so you may often multi-task while eating,

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I like cold drinks and such foods as ice cream.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

Spicy and hot foods upset my stomach.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I can't tolerate delaying or skipping a meal.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I consider myself efficient, ambitious and make quick decisions.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I try to be organized and accurate and sometimes overanalyze.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I try to be meticulous and am a perfectionist by nature.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I am impatient by nature and prone to compulsive thinking.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I have a strong will and my friends think I am stubborn.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I tend to have a short temper and become irritable or angry quite easily.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I don't hold a grudge.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I am usually critical of myself and others.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

Your Total Pitta!

Evaluating My Kapha Dosha

In Ayurveda Kapha dosha is associated with earth & water elements.

Many people consider me affectionate, forgiving, and peaceful.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I am very reluctant to take on new responsibilities.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

By nature I am calm and composed. I don't get angry easily.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

Skipping meals is easy for me and does not cause any problems.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

It is easy for me to gain weight but difficult to lose.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I have thick, oily, dark, wavy hair.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

My skin is smooth and soft with an almost pale complexion.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

My body frame is large and solid with a heavy bone structure.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

My digestion is slow, so I feel full after eating.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I have a steady energy level with good endurance and strong stamina.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I'm sensitive to cool and damp weather.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I tend to have congestion, mucus, or sinus problems.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I am not a quick learner but I am good at memorizing things and remembering them later.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I tend to be slow, methodical, and relaxed.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I need to sleep a minimum of eight hours to feel well the next morning.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I'm a sound sleeper.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

I usually oversleep and have difficulty waking up the next morning.

0-1 (Does not Apply)

2 (Applies Rarely)

3-4 (Applies Sometimes)

5 (Applies Often)

6-7 (Applies Most of the Time)

Your Total Kapha!

DHATU- Tissue catagory

What are your symptoms for each tissue.

NUTRITIVE ESSENCE WITH PLASMA (RASA) - The nutritive essence absorbed to the body after digestion

Very dry skin

Premature graying of the hair

Wrinkling of the skin at an early age

Excess mucus or respiratory congestion

A feeling of weakness and tiredness, lack of stamina, fluctuating energy levels

Ovarian or breast cysts now or in the past

BLOOD (RAKTA) - Blood tissue

Severe hot flashes or frequent feeling of excessive heat

Very heavy bleeding or “flooding”

Frequent or chronic skin rashes, acne, pustules, hives

Gallstones now or in the past (or have had gallbladder removed)

Bleeding hemorrhoids

Constant or problematic thirst

Lack of thirst

MUSCLES (MAMSA) - Muscle tissue

Constant muscle aches or pains, or easily fatigued muscles

Chronically swollen tonsils or lymph glands in the neck

Itchy ear canals or eczema of ear canals or excess ear wax

Fibroids of the uterus (now or in the past)

Fibrous or glandular lumps in the breasts

Severely dry, cracking lips

FAT (MEDA) - Fat and metabolism

Weight gain (at least 10 pounds overweight)

Inability to lose weight even on a low-calorie diet

High blood sugar (diabetes)

High cholesterol

Chronic or frequent problem with malodorous sweat or body odor

Fatty cysts under the skin or scalp or in the breasts

Thyroid disorder (diagnosed by a physician, including abnormal blood tests)

Frequent night sweats or sweats during the day associated with hot flashes

BONES (ASTHI) - Bone, cartilage, hair, and nail tissues

Low bone density (osteopenia) or osteoporosis

Hair breaking a lot (many split ends) or hair very dry and lacking luster

Problems with your teeth (breaking easily, many cavities, etc)

Nails breaking frequently

Constant joint pains or arthritic condition

Deep pains in the bones

BONE MARROW (MAJJA) - Bone Marrow

Frequent or recurring infections

Excess secretions of the eyes

Dryness of skin on upper eyelids

Constant spacey and distractible feeling, inability to focus or concentrate

Pain in the tendons, easily injured tendons, or recurrent tendonitis

Frequent feelings of faintness or dizziness

REPRODUCTIVE ESSENCE (SUKRA) - Reproductive fluids

Absence of libido (no sex drive)

Severe vaginal dryness

Overall feeling of lack of attractiveness

Dull, unclear eyes

Infertility

History of more than one miscarriage

Additional Dhatu Information

Malas- Body waste product

Describe as much as possible.

URINE

Frequent urinary tract infections

Frequent urinary burning

Bladder discomfort without infection

Strong smell to urine

Dark yellow urine even when you are drinking plenty of water

STOOL

Heavy stool that drops to the bottom of the toilet bowl

Very loose stool, diarrhea, or stool accompanied by mucus

Stool very hard, in small balls, difficult to pass or not eliminated every day

Undigested food visible in the stool

Stool always very foul smelling

SWEAT

Sweat irritates your skin or provokes rashes or infected sweat glands

Sweat smells bad

Unpleasant body odor

Too much sweat

No sweat, even when you are very hot

Additional Mala Comments

Ama Questionaire

What Is Ama in Ayurveda? Ama means toxin or undigested metabolic waste. It is a term to describe for all sticky, slimy, aggravating, and toxic substances accumulated in the body which cause imbalances and aggravation.

In the morning when I wake up, I'm groggy; it takes me quite a while to feel really awake.

1: Never

2: Rarely

3: Sometimes

4: Often

5: Always

I tend to feel blocked in my body (congested in the head, general lack of clarity, or other).

1: Never

2: Rarely

3: Sometimes

4: Often

5: Always

I tend to feel weak, physically, for no reason that I can see.

1: Never

2: Rarely

3: Sometimes

4: Often

5: Always

I get colds (or similar conditions) several times each year.

1: Never

2: Rarely

3: Sometimes

4: Often

5: Always

My body tends to have a feeling of heaviness.

1: Never

2: Rarely

3: Sometimes

4: Often

5: Always

I just tend to feel that "something isn't working right" in the body (digestion, breathing, bowel movements, or something else).

1: Never

2: Rarely

3: Sometimes

4: Often

5: Always

I tend to feel lazy. (My capacity to work seems all right, but I have no inclination.)

1: Never

2: Rarely

3: Sometimes

4: Often

5: Always

I commonly have indigestion.

1: Never

2: Rarely

3: Sometimes

4: Often

5: Always

I often feel the need to spit.

1: Never

2: Rarely

3: Sometimes

4: Often

5: Always

Often, I just don't have a taste for food. I have no appetite.

1: Never

2: Rarely

3: Sometimes

4: Often

5: Always

I just tend to feel tired, even exhausted...in mind or body.

1: Never

2: Rarely

3: Sometimes

4: Often

5: Always

Additional Ama Comments

The Three Gunas- Sattva, Rajas & Tamas

Diet

Vegetarian

Some meat

Heavy meat diet

Drugs, Alcohol and Stimulants

Never

Occasionally

Frequently

Sensory Impressions

Calm, pure

Mixed

Disturbed

Need for Sleep

Little

Moderate

High

Sexual Activity

Little

Moderate

High

Control of Senses

Good

Moderate

Weak

Speech

Calm and peaceful

Agitated

Dull

Cleanliness

High

Moderate

Give less importance

Work

Selfless, feel comitted to a cause

For personal goals, look forward to

Lack interest, feel lazy

Anger

Rarely

Sometimes

Frequently out of nowhere

Fear

Rarely

Sometimes

Live in constant fear

Desire

Little

Some

Excessive

Pride

Modest

Some ego

Vain

Depression

Never been a big issue

Some bouts

Very often feel sad and gloomy

Love and compassion

Universal

Mostly personal

Lack the feeling of love

Violent Behavior

Never

Sometimes

Frequently

Attachment to Money

Little

Some

Heavily attached

Jealousy

Never

Sometimes

Always feel jealous towards someone

Forgiveness

I forgive easily

With efforts

I hold long term grudges

Concentration

Extremely good

Moderate

Requires effort

Memory

Extremely good

Moderate

Requires effort

Willpower

Extremely strong

Varies

Weak. Requires effort.

Truthfulness & Honesty

Always

Most of the time

Rarely

Peace of Mind & contentment

Generally

Partly

Never

Creativity

Generally high

Moderate

Low & requires motivation

Spiritual or Motivational Study

Daily

Occasional

Never

Mantra chanting, meditation

Regular daily practice

Occasional practice

No interest

Community service

Generally

Occasionally

No interest

Affinity with nature

Extremely high

Moderate

Don't like outdoors

Helping others unconditionally

Always willing to

May be, may be not

Not my thing

Am I Satvic (0-30), Rajasic (30-60), Tamasic (60-90)

Diet & daily routine

Breakfast (Time, Solids, Liquids, Emotions)

Snacks (Time, Solids, Liquids, Emotions)

Lunch (Time, Solids, Liquids, Emotions)

Dinner (Time, Solids, Liquids, Emotions)

Cravings:

Alcohol Consumption

Yes

Daily Water Intake

Addictions:

Exercise routine and type:

Usual daily routine from morning till bed time.

Bed Time

Wake Up Time

Naps

Other Activities:

Disclaimer

The individualized Ayurveda consultation session/s offered by Vibha Rana of Green Tulip Health & Wellness LLC does not take the place of a medical evaluation, diagnosis, or treatment and Vibha will not diagnose any medical conditions or provide medical care. Results of Ayurvedic consultation and coaching vary and depend upon many factors including the individual’s current state of body, mind, and commitment to Ayurvedic principles. Ayurveda consultation by Vibha does not guarantee the results of any individual coaching, dietary supplement, lifestyle change, or the recommended Ayurvedic program as a whole. All information provided at the time of service is entirely educational in nature and is to be used at your own risk. I strongly advise you to consult with your primary care physician if you have any specific health issues e.g. chronic conditions, high blood pressure, prescription drugs and/ or any other that may contradict with the services, and whether these sessions are even right for you. Upon booking an appointment, you acknowledge to have read the disclaimer and agree to take full responsibility in accepting the consultation & coaching. You agree to hold Vibha Rana of Green Tulip Health & Wellness, LLC free from any liability when receiving this service. The sessions can be stopped at any time if the client and the consultant decide they are no longer effective or needed. As your Ayurveda Wellness Consultant it is my utmost responsibility towards my profession and my client/s that I protect his/her health information/s provided to me via the respective forms, during the in office, phone or zoom sessions and by emails. The information collected for this purpose will never be shared with another entity and will be protected.

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