Ayurvedic Intake Form

-For a pdf version click here-

Personal Info


Objectives & History


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


Evaluating my Pitta


Evaluating My Kapha

Some description about this section

DHATU

What are your symptoms for each tissue category.


Mala

What are your symptoms for each tissue category.


Diet & Routine


sunstoreleafmagnifiercrosschevron-down