Ayurvedic Health Questionnaire
Personal details
Date:
/
Surname:
First Name:
Date of Birth:
Married
Email:
Address:
/
Single
Tel No:
Occupation:
Children:
Health Goals:
Current Health Problems:
Signs & Symptoms:
Sleep:
Do you get to sleep easy?
Yes No
Do you feel rested when you wake up?
Yes No
Do you wake up in the night?
Yes No
What time? ………
Average hours sleep per night
Men’s Reproductive Health Do you suffer from:
 Excess urination
 Low libido
 Excess libido
 Infertility
 Impotence
 Prostate enlargement
Women’s Reproductive Health:
Date of last period
Cycle length
How many days does your period last?
Do you suffer from PMS? What happens? (woman only):
 Pain
 Mood Swings
 Breast tenderness
 Food cravings
 Anxiety
 Weight gain
 Breast distension
 Bloating
 Craving for sweets
 Clots
 Depression
 Lower back pain
 Low libido
 Fatigue
 Dizziness
 Excess libido
 Insomnia
 Water retention
Are you or have you been on the birth control pill?  No Yes How long?
History of past illnesses and treatment taken:
Current Medications:
Current supplements:
Weight & Height:
kg
cm
Work/Home lifestyle:
Lifestyle /Hobbies:
Do you smoke:  Yes  No How many per day?:
Past traumas / Date:
For how long:
Mother’s Medical History:
Father’s Medical History:
Sibling’s Medical History:
Allergies/Intolerances:
How do you feel after a meal:
Digestion Is your appetite (sensation of hunger):
 Erratic
 Sluggish
 Good
 Too good
 Balanced
 Do you get thirsty?
Do you suffer from:
 Wind or bloating
 Heartburn
 Nausea
 Bad breath
 Bleeding gums
Which is your favourite flavour?  Sweet  Salty  Sour  Spicy  Bitter
Breakfast:
Lunch:
Dinner:
Snacks:
Do you snack on nuts:
What Treats do you like:
Ulcers
Diet For the following foods please list percentage in your diet:
Raw food
‘Junk’ food
%
%
Meat
%
How much water do you drink?
Do you drink alcohol?
Fish
Dairy
%
%
Vegetables
Cooked food
%
%
Bread
%
glasses/day
 Yes No If yes, what types?
How often?
Do you drink coffee?
 Yes  No
How much?
cups/day
Do you drink tea?
 Yes  No
How much?
cups/day
Are you vegetarian?
Yes  No
If yes since when
Are you vegan?
 Yes  No
If yes since when
Bowels Movements:
Do you have a daily bowel movement?
 Yes  No
How many per day -1  2 
Do you have constipation?
 Yes  No
If yes how long for?
Do you have haemorrhoids?
 Yes  No
Do you have diarrhoea?
 Yes  No
Any other Comment??
Colour of feces?
3  4+ 
Practitioner To Fill Out
Other Information:
Tongue Diagnosis
Light - Heavy
Slightly - Very
Low – Good
Red

1 ____10
No coating

n/a
Thin

Vitality
1 ____10
Pink

1 ____10
White coating

1 ____10
Normal

Absorption
1 ____10
Pale

1 ____10
Yellow coating

1 ____10
Swolen

Very Pale

1 ____10
Grey coating

1 ____10
V Swolen

Cracks
1 ____10
Purple

1 ____10
Peeling tongue

1 ____10
Quiver

Dryness
1 ____10
Type of tongue: V / P / K
Mild - Advanced
Major Organ/s effected: ___________________________________________
Special tongue features___________________________________________________________________
_______________________________________________________________________________________
AGNI:……………………… Visamagni  (Irregular)
Mandagni  (Slow)
Vikruti ___________
Prakruti
___________
Cold
1 ____10
Ojas
1 ____10
Hot
1 ____10
Bala
1 ____10
Dry
1 ____10
Nails:
Wet
1 ____10
Hair:
Herbal formula /supplements prescribed:
______________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________________
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“ The Ayurvedic physician begins the cure of disease by arranging the diet that
is to be followed by the patient Ayurvedic physicians rely so much on diet that
it is declared that all diseases can be cured by following dietetic rules carefully
along with the proper herbal supplements; but if a patient does not attend to his
diet a hundred good medicines will not cure him ”
Charaka Samhita 1 41 - Ayurvedic text written in 600B C
GENERAL INFORMATION for inviting the healing process!
NO sugar NO Starch (No simple carbohydrates = No Processed grains No breads, biscuits, cereal),
absolutely NO soft drinks, NO product with added sugar NO FRIED FOOD
GREATLY LIMIT fruit juice, nuts, excess yoghurt, unfermented soy products, salad in colder season,
excessive RAW & COLD food when slow digestion an issue! Muesli and cold milk included
YES, YES YES unlimited fruits and vegies, ghee for cooking, complex carbohydrates, brown or basmati
rice, (real) organic oats well cooked with small amounts of warm organic raw (un-homogenized) milk if
tolerated, spices to match body type, kitchen herbs, food to flavour
AVOID leftover foods, fried foods, red meat, canned foods, frozen reheated foods, fast foods, nuts and
peanut butter, processed foods, prepacked chips, microwave foods, icy foods, avoid cheese, any food or
drink with added (or artificial) sugar Tap water (contains 32 chemicals), Avoid over indulgence in any
ONE FOOD!
FAVOUR fresh foods cooked daily, steamed vegies, vegetable soup (not from a packet), well ripened
fruits of the season, small amount of chicken and fish if required, herbal teas
FAVOUR ACTIONS Sip hot water - 1 cup three times per day Sip hot ginger water with meals to
increase digestion Keep the bowels open and aid detoxification THIS IS NUMBER ONE RULE! Eat
when hungry (3 meals per day) - Never Eat when NOT hungry If hungry outside of meals, snack on fruit
ONLY Never eat while digesting Never EAT with Coffee or Tea (chai is the exception) Limit tea and
coffee to one per day NEVER add sugar to your drinks IF YOU HAVE A HUGE SUGAR CRAVING
EAT ONE FRESH DATE
KITCHEN HERBS, FOODS & TASTES TO FAVOUR… Light & easy to digest
FAVOUR Bitter Sweet, Sour, Salty, Pungent, Astringent
TASTES to LIMIT Bitter, Sweet, Sour, Salty, Pungent, Astringent
Eumundi Medicine Man
1/10 Main St Palmwoods QLD 4555 Hours: 9am – 5pm Monday to Friday, Eumundi Markets Saturday ONLY
Email: info@eumundimedicineman com orders@eumundimedicineman com
Ph: 07 5478 8893 or 0411 297 448
Treatment plan for:____________________________
Follow up Visit: 2 weeks
3 weeks
4 weeks
Date: __________________ Time: ___________________
Cost of follow up consultation $__________or complimentary
SAFETY - Medications and Drug Interactions
Prescribed Dravyas:
__________________
__________________
__________________
__________________
______________________________________________________
AYURVEDIC DIAGNOSIS______________________________
_____________________________________________________
__________________
Cat / Cook / Safe/
______________________________________________________
PRIME GOALS OF TREATMENT
1 ____________________________________________________________________________________
2 ____________________________________________________________________________________
3 ____________________________________________________________________________________
start the day SD/between meals BM
COURSE OF ACTION – Take herbal medicine with hot water/with food WF/after food AF/
1 _______________________________________________________Dose_________WF/ AF/ BM/ SD
2 _______________________________________________________ Dose________ WF/ AF/ BM/ SD
3 _______________________________________________________ Dose________ WF/ AF/ BM/ SD
4 _______________________________________________________ Dose________ WF/ AF/ BM/ SD
Always drink warm or room temperature water never cold! Cold milk is toxic!
SPECIAL RECOMMENDATIONS
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
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AVOID CAUSITIVE FACTORS___________________________________________________________
______________________________________________________________________________________
Take what you need, and need what you take!
Eumundi Medicine Man
1/10 Main St Palmwoods QLD 4555 Hours: 9am – 5pm Monday to Friday, Eumundi Markets Saturday ONLY
Email: info@eumundimedicineman com orders@eumundimedicineman com
Ph: 07 5478 8893 or 0411 297 448