Vikruti Subdosha Questionnaire
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1 Vikruti Subdosha Questionnaire Quotes Gold Tantra Yantra, If you know your own mind, you know enough to keep it always positive FORM-DOSHA-QUIZ-VIKRUTI-EN-IMAGES.DOCX
2 Vikruti Subdosha Questionnaire - VATA VATA 1 I ve been having difficulty with mental clarity or the ability to focus my attention. 2 I ve been feeling overwhelmed, worried, or anxious. 3 My life has been turbulent and chaotic. 4 I ve been starting new projects, but have difficulty completing them. 5 I ve been having difficulty falling asleep or have been awakening easily. 6 I ve been having a hard time making decisions. 7 I ve been having trouble following through on commitments I ve made. 8 I ve been feeling restless if I m not constantly on the move. 9 I ve been acting impulsively or inconsistently. 10 I ve been more forgetful than usual. VATA total 1 I ve had a dry throat, have felt the need to frequently clear my throat, or have a dry cough. 2 I ve been experiencing gas, cramping, or bloating after meals. 3 My appetite has been inconsistent. 4 I ve been suffering from chronic pain. 5 My skin has been dry or flaking. 6 My bowel movements have been hard and dry or are irregular. 7 Men: I ve been having trouble getting sexually aroused, maintaining erections, or experiencing orgasms. 8 Women: My menstrual cycle has been uncomfortable or irregular or I am experiencing vaginal dryness. 9 I ve been getting light-headed when I get up quickly. 10 My hands and feet have been uncomfortably cold. 11 I ve been having muscle twitches, cramps, or heart palpitations. VATA total FORM-DOSHA-QUIZ-VIKRUTI-EN-IMAGES.DOCX
3 Vikruti Subdosha Questionnaire - PITTA PITTA 1 I ve been feeling discontented with my life. 2 I ve been judgmental and critical of others. 3 I ve been feeling jealous of others. 4 I ve been expressing anger towards others easily. 5 I ve been feeling irritable or impatient. 6 I ve been compulsive, with difficulty stopping once I ve started a project. 7 I ve been strongly opinionated, freely sharing my point of view without being asked. 8 I ve been frustrated by other people. 9 I ve been feeling the need to out-compete others. 10 I ve been ruminating over situations from the past. PITTA total 1 I ve been feeling overheated or have been experiencing hot flashes. 2 I ve been having headaches accompanied by light sensitivity or distorted vision. 3 My eyes have been itchy, irritated, red, or watery. 4 I ve been having more than two bowel movements per day. 5 My appetite has been excessively strong. 6 I ve been getting reflux/heartburn or have an ulcer. 7 I ve been sensing the accumulation of toxins (from food, air, water, alcohol, cigarettes, or drugs) in my system. 8 I've been diagnosed with some form of liver malady. 9 I ve been diagnosed with high blood pressure or coronary heart disease. 10 My skin has been itchy, irritated, prone to breakouts, or I ve been diag-nosed with an inflammatory skin condition. PITTA total FORM-DOSHA-QUIZ-VIKRUTI-EN-IMAGES.DOCX
4 Vikruti Subdosha Questionnaire - KAPHA KAPHA 1 I ve been dealing with conflict by withdrawing. 2 I ve been accumulating clutter in my life. 3 I ve been resistant to changing my routine. 4 I ve been having difficulty leaving a relationship, job, or situation even though it is no longer nourishing me. 5 My short-term memory has been of concern to me. 6 I ve been intending to be more physically active, but have difficulty exercising regularly. 7 I ve been eating more out of my emotional rather than nutritional needs. 8 I ve been having difficulty getting going in the morning. 9 I have not been confident in my ability to cope with challenges. 10 I ve been having a hard time moving beyond the past. KAPHA total 1 My ankles tend to swell. 2 I tend to be sluggish or lethargic in the morning. 3 I have a lot of phlegm or mucous production 4 I feel nauseated or full for an extended time after eating. 5 I am more than 10 pounds over my ideal weight. 6 I have high cholesterol or atherosclerotic heart disease. 7 I have been having episodes of asthma or wheezing. 8 I fall asleep easily after meals. 9 I have a tendency to have elevated blood sugars. 10 I have frequent sinus congestion or respiratory infections. KAPHA total FORM-DOSHA-QUIZ-VIKRUTI-EN-IMAGES.DOCX
5 For each question, choose the answer that best describes your current weight / eating patterns. Weigth VATA PITTA KAPHA I am currently underweight at my ideal weight overweight Under stress my appetite diminishes I become I eat even when I don t feel hungry It is easy for me to lose weight maintain a stable weight Gain Totals Total Total Total Dosha VATA- score PITTA- score KAPHA- score VATA- score PITTA- score KAPHA- score Quotes Photo Credits: Skaftafell, Iceland Chris Zimmermann, Keep your mind fixed on what you want in life, not on what you don t want FORM-DOSHA-QUIZ-VIKRUTI-EN-IMAGES.DOCX
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Consultant Name: NEW PATIENT QUESTIONNAIRE Health Care Analysis CONGRATULATIONS! You ve taken an important step in your commitment to managing your weight. We look forward to working with you. Our Program
Patient Medical History Form
Patient Medical History Form Name: DOB: Sex: M F Street Address: City: State: Zip: Home Phone: Work Phone: Cell Phone:_ Email: Emergency Contact: Phone: Primary Care Physician: Phone: How did you hear
This questionnaire is designed to find out how you have been feeling during the last two weeks. Please circle only one number for each question.
This questionnaire is designed to find out how you have been feeling during the last two weeks. Please circle only one number for each question. 1. How frequent have your bowel movements been during the
3. Male? 4. Hydrocortisone (or derivates)? 5. Other? Vitamins/minerals/trace elements: How are you doing? very well well average not well very bad
LAUREN CIEL SWERDLOFF MD INCORPORATED 1821 WILSHIRE BLVD. SUITE # 220 SANTA MONICA, CA 90403 (310) 829-5189 FAX: (310) 829-5942 Could you please fill in this questionnaire and bring it at the next appointment?