Ayurveda Dosha - Questionnaire

The Ayurveda Dosha Questionnaire serves as a foundational tool to determine an individual's dosha constitution in Ayurvedic medicine. This questionnaire typically comprises a series of thoughtfully crafted inquiries regarding one's physical, mental, and emotional tendencies, lifestyle choices, and preferences. By analyzing the responses, practitioners can assess the dominant doshas—Vata, Pitta, and Kapha—within a person's unique constitution. This assessment guides personalized recommendations for diet, exercise, daily routines, and holistic practices aimed at restoring balance and well-being in accordance with Ayurvedic principles.
Email *
All information is subject to medical confidentiality
Name *
Surname
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  Street  
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Postal code, Place  
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  Birth date   
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MM
/
DD
/
YYYY
  Marital status
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  Children  
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  Height  (Cm)
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  Body weight  
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  Health insurance company  
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  Profession  
  Occupation  
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Date of arrival  
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MM
/
DD
/
YYYY
Date of departure  
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MM
/
DD
/
YYYY
  Telephone   
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  E-Mail  
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Room No. (please enter, if you are in the hotel)  
Do you have acute or chronic complaints?   
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Do you currently have psychological or psychosomatic complaints?  
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  Do you have food intolerances? Which?   
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Required
Are you undergoing a special diet?   
  Are you aware of allergies? Which?   
  What childhood problems did you experience?   
Are you aware of any ilnesses in your familiy, especially in the case of father, mother or siblings?   
  Have you had surgeries or an accident, if so, please explain?   
Are you suffering from indigestion (constipation, diarrhea, flatulence, heartburn)?   
Have you taken medication (including antibiotics, cortison, sleeping pills and psychiatric drugs) in the past three months or are you taking medication permanently?   
Do you have the following chronic diseases? (please check)   
  How often do you taken the following remedies?   
Regularly
Occasionally
Never
Coffein
Nicotine
Alcohol
Clear selection
  Drugs? Which kind? How often?    
The following questions only concern female:
Do you have gynecological/climacteric complaints?   
Surgery in the uterus or in the urogenital tract?  
  When was your last menstruation?   
The following questions only concern male:
Do you have complaints in the urogenital tract (e.g. prostate)?
  Operations?  
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Please fill out the following three columns which really applies to you.
slim, unusually large
medium-sized
corpulent, strong, rounded
Anatomy
Clear selection
light, delicate
medium-sized bone structure
heavy bone structure
Bone structure
Clear selection
protruding, dry, possibly rubbing noice, cold
medium-sized, loose
large, slippery, well padded
Joints
Clear selection
Column 1thin tissue, rather, dry cold, generally rough
oily, smooth, warm, freckles if necessary
thick, oily, cold, even, complexion
Skin
Clear selection
elongated, narrow shape
rather round shape
strong, broad, meaty
Hands
Clear selection
elongated, thin, rough surface, possibly brittle
round, soft, rosy color
broad shape, smooth, thick, firm
Nails
Clear selection
elongated shape, asymmetrical, possibly furrowed
sharp-edged features, possibly wrinkled forehead
round, full, large & smooth forehead
Face
Clear selection
small, active, possibly dry, fine brows
medium-sized, bright, penetrating
large, quiet, glassy, strong, brows
Eyes
Clear selection
fine, possibly dry,fluffy, sparsely populated
bright, silky,bright, possibly bald
full, thick hair, dark, wavy
Scalp hair
Clear selection
thin wavy hair
fine, flying, blonde hair
dark, thick, curly hair
as a child...
Clear selection
ruffled, not shiny
light, silky, fine
bushy, dense, strong
Body hair
Clear selection
small, irregular, possibly grayish
medium in size, possibly a slight yellowing
large, regular, bright
teeth
Clear selection
gentle, quiet, possibly rough
impulsive, penetrating, clear
deep, pleasant, sonorous
voice
Clear selection
always irregular, generally little
generally "good hunger"
regular & moderate
hunger
Clear selection
always been relatively weak
medium, susceptible to infections
generally strong & reliable
Immunity
Clear selection
good short power, no endurance type
dynamic, lovescompetition
slow but strong, persistent
sportiness
Clear selection
many friends, inconsistent
moderately many, but useful friends
little relationships but long lasting
Friendship
Clear selection
creative activitiesdancing, traveling
Sport, club activities, organizing
quiet activities, collecting,m reading, cuddling
Hobbies
Clear selection
quick grasp, clear
precise, concise, fiery
slow, well considered, sensitive
intellect
Clear selection
spontaneously, sometimes without a degree
critical, rational, carefully considered
relaxed, traditional
reaction
Clear selection
tolerant, imaginative, flexible, curious, scattered
confident, determined, organized
calm, leisurely, stable, patient
Ghost
Clear selection
Your laboratory reports: Please bring (if available) laboratory reports and other findings from the last six months.
I hereby confirm that all questions have been answered according to my understanding. I am informed that my information is provided on a voluntary basis. Please note that Ayurvedic treatments and therapies can only be given after completing and signing this document. I hereby consent to the processing and storage of my data for the stay current and future until further notice. *
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A copy of your responses will be emailed to .
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