Live Well Nutrition and Ayurveda

Ayurvedic Intake Form

INSTRUCTIONS

The following simple test will give you a fairly good idea of the levels of your doshas. Please 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

Does Not
Apply

2

Applies
Rarely

3-4

Applies
Sometimes

5

Applies
Often

6-7

Applies Most
Of The Time
Ayurvedic Intake Form

Intake Form Start

Evaluating Your Vata

Physical Attributes:

Mental, Emotional, and Behavioral Attributes:

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Ayurvedic Intake Form

This intake form helps me gain insight into your unique body-mind makeup from an Ayurvedic lens. We will uncover which primary energies or doshas are most present in your body and mind and where we need to work on balancing.

Health Intake Form

The general health intake form will give me an overview of your current health concerns and help to identify what you would like to accomplish regarding your health as well as uncover some key areas for improvement. Your personal information remains safe and secure.

Pediatric Intake Form

The Pediatric Intake Form should be completed by the child's guardian. This form will give me an overview of your child's current health status and help to identify areas of improvement regarding their health. Your child's information remains safe and secure

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