Are you an active smoker? YesNo
If yes, how many cigarettes do you smoke in a day and since when?

Do you exercise regularly? YesNo
If yes, please specify the frequency in a week and type of exercise.

How many hours of sleep do you get on average?

Choose one of the sleep patterns most suitable to your routine.GoodFairBroken

Do you feel muscular tension? YesNoIf yes, please specify the frequency in a week and type of exercise.

Do you regularly and easily feel under pressure? YesNo

Do you relax on weekends or take vacations regularly?YesNoIf yes, how frequently?

How many hours do you work per day? YesNo

Have you had any accidents or injuries? YesNoIf yes, please specify the approximate time period.

Do you have any metal plates/pins in the body?YesNoIf yes, where?

Do you suffer from any of the below:
Leg crampsBack/neck stiffness or painStiffJoints if yes, which ones: AchesPainsSensitive areasOthers, please specify:

Do you suffer from any of the below ailments?
Cardiac problemsBlood pressure
Please specify high or low. HighLowIf yes, where?
Varicose veinsBroken veinsCelluliteKidney problemsCold hands &; feetPalpitationsDo you have a pacemaker in the body or have had a bypass surgery? If yes, please specifyduration since or when the surgery was.

Are you pregnant or have had children? Did you go through a normal delivery or had a caesarean?

Do you suffer from any of the below?
P.M.TMenopauseHormone Imbalance

Do you take any HRT (Hormone replacement treatment)supplement? If yes,which ones?

Have you previously suffered or are suffering from any of these ailments?
Stroke or paralysis?Migraine or tension related headachesEpilepsyInsomniaWeakness or sensitivity

How would you rate your appetite? Choose one.
GoodPoorErratic

How would you rate your digestion and bowel movements? Choose one.
RegularPoorErratic

Do you suffer from any of the below?
UlcersConstipationIBS (irritable bowel syndrome)

Are you prone to any of the below conditions? If yes, how frequently?
Cold, sore throat, chest congestion. Do you take antibiotics?SinusitisAllergiesHay feverAsthmaBronchitisJaundiceEczemaPsoriasisFainting spellsVertigoClaustrophobiaAnemiaAllergy to specific things like iodine, seaweed or any food types? Please specify.

Infectious skin diseases.

Are you undergoing any other medical treatment? If yes, please specify what.

Are you on any regular off the shelf drugs? If yes, please specify which ones.

Do you take any other supplements? If yes, please specify which ones.

Are you consulting any other practitioner like Osteopath, Ayurveda, Naturopath, Homeopath, and Acupuncturist? If yes, for what ailment.

How many meals do you eat in a day?

Which is your biggest meal?

Do you eat in between meals? If yes, how frequently?

Do you have any food aversions or allergies?

In a week, how many times do you eat the below.
Non-Veg other than fishEggPizza / BurgerBiscuitsSweets / Desserts MilkJam/ SaucesYogurt (curd)Instant FoodsButter / Cream / GheeSoft drinksCheese (paneer)SugarWater (per day)CoffeeTea Ice CreamMilkShakesChocolates Type of oilFried foodsPickleLeafyVegetablesFresh FruitsDry FruitsVegSaladsCereals Pulses

Please specify a number.

Please check one statement that best describes you. Occasionally, there may be two statements that are most suited.
Thin & unusually tall or shortMedium bodyLarge body

Light, small bones &/ or prominent jointsMedium bone structureHeavy bone structure

Long tapering fingers & toesFingers & toes are medium in lengthFingers & toes are short

Thin built as a childMedium built as a childLarge built as child

If gains weight around middleIf gains weight, deposits fat evenlyTend to gain weight, especially in rear & thighs

Dark complexion (relative to family) & tans easilyFair skin, sunburns easily, freckles and molesTans evenly

Scanty body hair or over abundant, tends to be dark & curlyLight body hair fine textureModerate amount of body hair

Small foreheadMedium forehead with folds & linesLarge forehead

Small dark eyesMedium size light green, grey, amber or blue eyesLarge, liquid, sometimes blue or brown eyes

Crooked, uneven teeth,sensitive to heat & cold & may have needed bracesEven teeth of medium sizeLarge, even teeth

Small NeckModerate NeckLarge Neck

Small ChinModerate ChinLarge Jaw

As a child curly hairAs a child fine & lightAs a child thick

Total

Please check one statement that best describes you. Occasionally, there may be two statements that are most suited.
Difficulty in gaining weightCan gain or lose weight if determinedGains weight easily, hard time losing without exercise

Cold hands & feetSkin warm to touchSkin cool to touch

Dry skinOily skin prone to pimples & rashesThick skin well lubricated

Often suffers from cracked and chapped lipsDeep red lipsMoist lips

Dry hair, lusterless, split ends, dark rough, wiryFine light, oily, blonde, red or early grey hair, early thinning or baldnessThick slightly wavy hair, a lile oily, dark brown, lustrous

Dislikes dryness & cold (likes warmth)Prefers cool, well ventilated places, dislikes heatTolerates most climates, dislikes humidity

Dry with thin, greying coatingTongue coating yellowish, reddishSwollen, with thick curdy white coating

Eyes often dry, scratchy sclera greyishSclera has reddish or yellow tingeTendency towards eye puffiness

Bowel movement can be irregular, hard, dry or constipatedBowels loose, more than twice a dayLarge full bowel movement once a day, mucous

If ill, prone to nervous disorders, sharp painProne to fever, rashes or inflammationIf ill, prone to swelling, fluid retention, mucous congestion

Variable sexual interest, fantasy life activeMore sexual interest, arouses easilySteady sex, slow to arouse

Menses’ irregular, scanty flow, severe painful crampsMay bleed heavily & long loose stool accompanies periodsProne to water retention during menses, slight cramps if any

Either indulges in rich food or on strict dietLoves protein food, caffeine & hot, spicy & salty foodsLoves sweets, dairy products, pastry

Receding gumsInflamed bleeding gumsThick gums

Joints: painful, unsteady, cracking or stiffJoints: Hot, swollen& burningJoints: Aching, watery & swollen

Total

Concentration is short, short- term memory, good but forgets quicklyGood, short- & long-term memory, logical & rational thoughtsTakes time to learn things, once learned never forgets

Dislikes routineEnjoy planning and organizing, especially if self-createdWorks well with routine

Difficulty in deciding, changes mind easilyRapid decision making, sees things clearlyTakes time making decision, sticks with it

Restless, active, likes movementAggressive, likes competitive activitiesCalm, likes relaxing, leisure activities

Creative thinkerOrganised thinkerPrefers to follow up a plan or idea

Does many projects all at onceConstantly organizing likes to proceed in orderly fashionResists change, new projects, likes simplicity

Knows lot of people, but a few close friendsVery selective, but creates warm friendships, makes enemies easilyLoyal with many friends

Spends impulsively, money is to be usedPlans spending, money is for achieving purposeSpends reluctantly, likes to save

Total

Experiences fearExperiences HateExperiences Apathy

Practices secretivenessCan be Vindictive (Revengeful)Can be Straight forward

Can be self-destructiveCan be destructiveFeels Victimized

AnxiousIrritableAttached

SneakyManipulativeGreedy

NervousAngryDesirous

DynamicPerceptiveHarmonious

CommunicativeCaringDevoted

FlexibleTolerantPatience

Feelings & emotions change easilyAggressive about opinions & feel things, gives opinions even if not askedAvoids giving opinions in diicult situation

Dreams about flying, restless, nightmaresColorful dreams, fast, passion, conflictsRomantic Short dreams often involve water

Total