Ayurveda Nutrition Assessment Form
Ayurveda Nutrition Assessment Form
Please fill out this form completely to help us assess your nutritional needs based on Ayurvedic principles.
Personal Information
Name
Date of Birth
Age
Phone number
Lifestyle and Dietary Habits
How many meals do you typically eat in a day?
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1
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2
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3
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More than 3
Do you have regular meal timings?
How often do you consume the following?
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Fresh fruits |
|
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Vegetables |
|
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Dairy Products |
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Health and Digestion Assessment
Do you experience any of the following frequently?
(Check all that apply)
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Bloating
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Constipation
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Acid reflux
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Fatigue after meals
How would you describe your appetite?
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Low
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Moderate
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High
How much water do you drink daily?
Ayurvedic Dosha Analysis
Which of the following best describes your general tendencies?
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Dry skin, irregular digestion, light sleeper (Vata)
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Warm body temperature, strong appetite, prone to acidity (Pitta)
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Heavy build, slow digestion, sound sleeper (Kapha)
Signature
I confirm that the information provided above is accurate to the best of my knowledge.
Name:
Date:
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