Ayurvedic Dosha Quiz | Twin Beans Farm

Twin Beans Farm · Ayurveda

Prakruti

Vikruti

For a consultation, please email your quiz results, Health Intake, and photos to Twin Beans Farm: twinbeansfarm@gmail.com

Health Information & History Intake

* Required information

Personal Details

Full name *

Address

Email *

Mobile phone *

Date of birth *

DD/MM/YYYY

Marital Status

Occupation

Referred by (if any)

Objectives

Select the item below that reflects your main objective (one only). Please note that Ayurvedic Consultations do not include medical diagnosis and treatments. If you are concerned about a medical condition, you should see a medical doctor.

I want an alternative approach to allopathic medicine for managing illness and disease I want to improve my general health and wellness and reduce my vulnerability to illness and disease I want to improve my lifestyle and dietary practices to improve my health I want to change my habits and behavioral patterns to improve my relationships with others I want to manage stress, tension and worry to attain a more stable emotional nature

What do you want to achieve in terms of your health and wellness? Please also tell us your current concerns.

Medical History & Current Treatment

Check appropriate boxes if you or your family members have a history of the following:

Any Other Diseases Or Problems? (Illnesses, injuries, addictions, weight changes, surgeries, etc.)

Are you currently under a physician’s care?

What prescription drugs are you taking (including birth control)?

What non-prescription drugs, supplements, or recreational substances are you taking (including alcohol, tobacco, caffeine)?

Current Health Concern

From the health concerns you listed above, please choose ONE condition or symptom that you are most concerned about or would most like to focus on during this consultation.

Please identify ONE condition or symptom that you are most concerned about or would most like to improve at present (for example, stress or insomnia).

1. Short description *How do you experience this condition/symptom?

2. Frequency *How often does the condition/symptom occur?

3. Intensity *How intense is it?

Mild Moderate Severe

4. Duration *For how long have you had this condition/symptom?

5. What have you done to address it? *Has this condition been evaluated by a medical professional? Are you currently receiving any medical treatment for it? Have you tried any home remedies or other approaches?

Additional notesPlease provide any other information you would like us to know.

Current Health & Vitals

Last Physical Exam Date

Height

Weight

Yoga & Meditation Experience

YOGA

Do you practice Yoga or any other form of physical exercise? *

Yes No

If yes, how long have you practiced, and how many sessions per week?

Where do you practice, and with which Yoga teacher or tradition/style?

Do you practice breathing exercises or Pranayama? *

Yes No

If yes, please list the breathing practices you use.

MEDITATION

Do you practice meditation? *

Yes No

If yes, how often do you practice?

Do you practice on your own or with a group?

Which meditation tradition, school, or philosophy do you follow?

Diet & Elimination

Please write down all food you have eaten and drank for the last three days, with timing.

When and how often do you eliminate? What does your poop look like (color, shape, quantity, odor)?

Required Photos

Please email the following photos at least 48 hours before your first appointment. You may send the photos individually or provide a Google Drive link. You do not need to send every photo if your consultation is in person; however, providing photos is still encouraged to support a more thorough assessment.

Full length photo from the front
Full length profile from the side
Close up of face
Close up of both hands, palms downward
Entire top of the tongue, including the back (ideally photographed immediately after waking, before tongue scraping)
Close up of eyes looking to the right & left
Full length childhood photo before the age of 5

For a consultation, please email your quiz results, Health Intake, and photos to Twin Beans Farm: twinbeansfarm@gmail.com