Form | Sarah Rigueira

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Ayurveda Anamnesis Questionnaire

1. Personal Information

Full name

Birthday * required

Gender * Required

Woman

Man

Prefer not to say

Email

Address

Country

Phone number

Occupation

Type country

Marital status

2. Healthy History

Have you ever been diagnosed with a medical condition?

No

Yes

If yes, please provide details:

If yes, please provide details:

Do you take any medication(s)?

No

Yes

If yes, which one(s)?

If yes, which one(s)?

Family history of desease(s)?

No

Yes

If yes, please specify bellow:

Any surgeries or significant hospitalizations?

No

Yes

If yes, please specify bellow:

If yes, please describe:

If yes, please describe:

3. Lifestyle

Describe your daily routine:

Describe your daily routine:

Sleep pattern:

Sleep pattern:

Physical activity:

Physical activity:

Consumption of:

Alcohol

Tobacco

Other substances

None of these

If you check one or more of the options above, please specify other substances and frequency for each one:

If you check one or more of the options above, please specify other substances and frequency for each one:

4. Nutrition

Check for themain meals on your routine:

Breakfast

Yes

No

Lunch

Yes

No

Breakfast time

Lunch time

Afternoon snack

Yes

No

Afternoon snack time

Dinner

Yes

No

Dinner time

Food preferences:

sweet

salty

spicy

fatty

You can add more details about your food preferences bellow:

You can add more details about your food preferences bellow:

Do you eat meat?

Yes

No

If yes, type and frequency:

If yes, type and frequency:

Daily water intake:

less than 4 cups (1L)

2 - 8 cups (1L - 2L)

8 - 12 cups (2L - 3L)

More than 12 cups (3L)

Not sure

Known intolerances or allergies:

Known intolerances or allergies:

5. Digestion and Elimination

Appetite level:

Low

Mild

Moderate

Hight

Very High

Not sure

Describe how you usually feel after eating:

Describe how you usually feel after eating:

Bowel movements (frequency, consistency, color):

Bowel movements (frequency, consistency, color):

Presence of gas, heartburn, constipation, or diarrhea:

Presence of gas, heartburn, constipation, or diarrhea:

Urination (frequency, color, discomfort):

Urination (frequency, color, discomfort):

6. Energy and Emotions

Energy level:

1

How do you handle stress?

How do you handle stress?

Do you experience frequent mood swings?

Yes

No

Predominant emotions:

Predominant emotions:

7. Female Cycle & Reproductive Health

Age of menarche (first menstruation):

Menstrual cycle:

Regular

Irregular

Menstrual symptoms:

Cramps

PMS

Heavy flow

Low flow

More informations if apply:

More informations if apply:

Use of contraceptives or hormonal methods?

Yes

No

If yes, describe bellow:

Fertility and pregnance history:

Pregnancies

Births

Miscarriages

If yes, describe bellow:

Details:

Details:

How is the level of your libido and sexual vitality currently?

1

Menopause symphtoms (if applicable):

Menopause symphtoms (if applicable):

8. Ayurvedic Evaluation

Predominant body temperature:

Feel more heat

Feel more cold

Not sure

Skin type:

Dry

Oily

Sensitive

Mixed

Not sure

Hair type:

Thick

Thin

Dry

Oily

Not sure

Body structure:

Slim

Athletic

Robust

Not sure

Mind pattern:

Anxious

Practical

Creative

Slow

Not sure

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