Ayurvedic Initial Consultation Form

-For a pdf version click here-

Ayurvedic Intake

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. 




3 – 4


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.

Evaluating my Pitta Dosha

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

Evaluating My Kapha Dosha

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

DHATU- Tissue catagory

What are your symptoms for each tissue.

Malas- Body waste product

Describe as much as possible.

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. 

The Three Gunas- Sattva, Rajas & Tamas

Diet & daily routine