• This CONFIDENTIAL form is about your current health and well-being. It is to see how things have changed since your therapy with us.

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

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

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
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.
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
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
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)
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
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. *