We need information about your current health and well-being to provide the highest quality service. To keep your costs to a minimum we ask that you provide this information in advance through this assessment form.

  • This form takes around 15 minutes to complete, it will tell us about you and and how we can best help and advise you.

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

  • No need to answer everything, but the more you answer, the better.

  • This form will be emailed directly to your Manasa Ayurveda therapist for analysis. It won’t be shared or stored anywhere else (see our Privacy Policy).  

Urine hydration chart

Urine hydration chart

Alcohol units

Alcohol units

Stool chart

Name *
Name
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
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)
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
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 well-being 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 sent to this address are not shared with any other parties or organisations outside of Manasa Ayurveda Ltd. I understand that Manasa Ayurveda products (oils, herbs etc.) are not medicines for treating or curing disease. I am aware of the advice to also 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.