• This CONFIDENTIAL form is about your current health and well-being. It is the first part of your online consultation; the second part will be your telephone appointment.

  • This form is best completed on a computer, laptop or tablet (if necessary, use your phone, but all options may not be fully visible).

  • If you answer only the REQUIRED questions it takes around 5 minutes.

  • If you also answer ALL of the OPTIONAL questions it can take up to 30-40 mins.

  • Please answer as much as you can so we can understand how best to support your health and well-being.

Urine hydration chart

Urine hydration chart

Alcohol units

Alcohol units

Stool chart

REQUIRED
Name *
Name
Tell us later if you prefer
Once required questions are answered, whenever you are ready you can affirm the statement at the bottom of this form and click 'submit'.
It's fine to skip any of the optional questions below if you don't feel comfortable sharing this information, but the more you answer the more we'll understand how best to support your health and well-being.
OPTIONAL
Please note: Manasa Ayurveda services are only for those aged 18 and over
Diet & Digestion
Bannanas, Cashews, Cherries, Honey, Mango, Peaches, Pineapple juice, Sweet peppers, Sweet potato
Coffee, Lemon, Lime, Pickles, Sour fruits, Tomatoes, Vinegar, Tamarind
Celery, Kelp, Miso, Seaweed, Soy sauce, Salt
Black pepper, Cloves, Garlic, Horseradish, Hot peppers, Mustard, Onions, Radishes
Aloe vera juice, Artichoke, Chard, Neem
Aduki beans, Apple juice, Berry juice, Black beans, Black eyed beans, Brown lentils, Kidney beans, Lentils, Leafy greens, Okra
You can tell when you're not able to digest food very well you experience things like gas, bloating, stomach pain, constipation, heartburn or fatigue after eating.
Effects could be things such as gas, bloating, stomach pain, constipation, loose stools, heartburn or fatigue after eating.
As a general guide, if your digestion takes longer than normal you might eat a meal and feel stuffed for the next six hours or longer. If your digestion occurs quite quickly than normal you might be running to the bathroom soon after each meal.
According to Ayurveda, lunch is the most important meal of the day, ideally eaten between noon and 2 pm. But the scheduled time for having food is set by the rhythm of your body. It is the time when your body is signalling to you by making you feel hungry.
Elimination
Check the stool chart above
(see urine hydration chart above)
Caffeine & Alcohol
(see alcohol units chart above)
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
(add up all the time you are awake)
affected your mood, energy, or relationships?
affected your concentration, productivity, or ability to stay awake?
troubled you in general?
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.
Feelings, thoughts & behaviour
A) Mentality (feelings & emotions) that is out of character
(please tick any that you have experienced in the past month)
B) Behaviour (habits and actions) that is out of character
(please tick any that you have experienced or exhibited in the past month)
C) Cognition (thoughts and thinking habits) that is out of character
Physical condition
Physical condition
Please tick any areas where you have experienced any problems or anything of concern (we may ask you more about these later)
AFFIRM & SUBMIT
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. *