Ayurveda Nutrition Assessment Form
Name Of The Client
First Name
Last Name
Age / Gender
Age
Gender
Health Concern: History 1.
Health Concern: History 2.
Other Concerns.
Any History Of Hospitalisation Or Continuous Medication Including The Supplements.
Any History Of Parent / Siblings - Hospitalisation Or Continuous Medication Including The Supplements.
Bowel - Appetite - Micturition - Sleep - Digestion - Hemorrids
Breakfast, Lunch And Dinner Patterns.
Pulse - Nadi
Vata - Varying and irregular
Pitta - Regular and bouncing
Kapha - Slow and gentle
Body Temperature - Sparsham
Vata - Cold hands and feet
Pitta - Warm body
Kapha - Clammy and users heater always
Body Physic - Roopam
Vata - Slender and boney prominence
Pitta - Medium built or cahnge of skin colour
Kapha - Heavy built or oily skin
Auditory - Shabda
Vata - Weak voice or breathing sounds
Pitta - Active voice or dominant
Kapha - Gentle voice or mucousy chest
Eyes - Netra
Vata - Small or dry
Pitta - Medium or red or muddy
Kapha - Big or mucousy
Stool - Pureesha
Vata - Floating
Pitta - Loose
Kapha - Sinking
Urine - Mutra
Vata - Dark
Pitta - Yellowish
Kapha - Whitish
Tongue - Jihwa
Vata - Dark
Pitta - Yellowish
Kapha - Whitish
Level Of Ama
Srotorodha - Blocked ear / Sinus / Congrestion
Balabramsha - Weakness and tired
Gauravam - Heaviness and dull
Anila Moodata - Low appetite
Alasya - Lethangry in the morning
Apakti - Reduced digestion
Nisteeva - Salivation
Mala sanga - Constipation
Aruchi - Reduced appetite
Klama - Mentally exhausted and confused
Emotional State
History of trauma
Childhood difficulties
Stress from workplace
Difficulty to manage stress
Lack of motivation
Submit
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