This online mind-body assessment consists of multiple-choice questions and gives space for you to describe any problems you might have (the form takes around 15 minutes to complete). Completion of this mind-body assessment forms the first part of your personal online and face-to-face consultation. When you book your consultation, once submitted, this form is emailed directly to a Manasa Ayurveda therapist for analysis.

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).  

  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.
Thoughts, feelings and behaviours - below are a number of words that describe different thoughts, feelings and behaviours. Read each item and then select the appropriate answer below that word. Indicate to what extent you have thought, felt, or acted this way toward yourself and others during the past WEEK
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
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. *
I understand and acknowledge that Manasa Ayurveda Ltd. services are intended for general wellbeing and follow the principles of Ayurveda. I understand that the Ayurvedic therapist may suggest foods, massages, meditation, exercises and lifestyle based on the information I share, and I consent that the therapist can apply massage for therapy unless specified differently. I confirm that all information I give, both personal and medical is/will be complete and accurate to the best of my knowledge, and I agree to keep the therapist updated as to any changes in my medical profile. I understand that once submitted, forms on the Manasa Ayurveda website and booking system may be sent directly to the email address: admin@ManasaAyurveda.com and that form submissions are not shared with any other parties or organisations outside of Manasa Ayurveda Ltd. I understand that Manasa Ayurveda products are not medicines for treating or curing disease. I am aware of the need to consult with my General Practitioner (GP) or medical/nurse practitioner with health concerns - particularly if pregnant, breastfeeding, with any health condition or when taking medication. I give consent for my anonymised feedback and clinical outcomes (without my name or personal identifiers) to be presented or published. I understand and agree to Manasa Ayurveda Ltd. Terms and Conditions and Policies and give consent for details of my physical or mental health to be documented and stored according to the Manasa Ayurveda Ltd. Privacy Policy.