This online mind-body assessment takes around 15 minutes to complete. It is better to complete this form on a computer, laptop or tablet. If necessary you can use your phone, but all options may not be fully visible. Please answer as much as you can. The more you answer, the more Manasa Ayurveda can personally tailor for you. The information you provide will not be shared outside of Manasa Ayurveda and will be respected with confidentiality (see our Privacy Policy).  

   
  
   
  
    
  
   Normal 
   0 
   
   
   
   
   false 
   false 
   false 
   
   EN-GB 
   X-NONE 
   X-NONE 
   
    
    
    
    
    
    
    
    
    
   
   
    
    
    
    
    
    
    
    
    
    
    
    
    
  
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
  
   
 
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   Urine hydration chart

Urine hydration chart

  Alcohol units

Alcohol units

Stool chart

Age & gender
Please note: Manasa Ayurveda services are only for those aged 18 and over
Physical activity - please tell us about your current level of physical activity
Sleep - please tell us about how you have been sleeping over the past month
Current fluid intake - please tell us about your consumption of fluids
(see alcohol units chart above)
Digestion - please tell us about your digestion
Elimination
Check the stool chart above
(see urine hydration chart above)
Menstrual disorders
Please indicate if you have experienced any of the following within the past 3 months
Memory - As compared to when you were in High School or College, how would you describe your ability to perform the following tasks involving your memory?
Day-to-Day Experiences - Below is a collection of statements about your everyday experience. Please indicate how frequently or infrequently you currently have each experience. Please answer according to what really reflects your experience rather than what you think your experience should be. Please treat each item separately from every other item.
Current condition - please tell us about the current condition of your body, mind and behaviour
A) Behaviour (habits and actions) that is out of character
(please tick any that you have experienced or exhibited in the past month)
B) Mentality (feelings & emotions) that is out of character
(please tick any that you have experienced in the past month)
C) Cognition (thoughts and thinking habits) that is out of character (A)
D) Sleep/drowsiness/physical strength
E) Burning sensation & changes in body temperature
F) Skin and nails
G) Head, hair & face
H) Eyes
I) Ears & nose
J) Mouth & throat
K) Arms & legs
L) Ankles & feet
M) Pelvis, rectum & groin
N) Chest, abdomen, back & neck
O) General physical issues
Name *
Name
General Data Protection Regulation (GDPR) *
Once submitted this form will be sent directly to our email address: admin@ManasaAyurveda.com. Form submissions are not shared with any other parties or organisations outside of Manasa Ayurveda Ltd.
I affirm that I have stated all my known medical conditions and have answered all questions honestly. When using these services I agree to keep Manasa Ayurveda updated as to any changes in my medical profile. *
[Please note: Our herbal products are not medicines. Our herbal beverages are offered as substitutes or alternatives for coffee or tea etc. They are not for treating or curing disease, but meant as part of your personal healthy diet. If you are planning to self-medicate with any herbs or make significant changes in diet or lifestyle for health, please consult with your GP or medical/nurse practitioner; particularly if you are pregnant, breastfeeding, have a health condition or are taking medication].