Ayurveda Nutrition Assessment Form

Helps an Ayurvedic practitioner record a patient's health history, eating habits, and physical observations before recommending dietary changes.

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Name of the Client

Nombre

Apellido

Age / Gender

Nombre

Apellido

Health Concern: History 1

Health Concern: History 2

Other Concerns

Any History of Hospitalization or Ongoing Medication, Including Supplements

Any History of Hospitalization or Ongoing Medication Among Parents/Siblings, Including Supplements

Bowel - Appetite - Urination - Sleep - Digestion - Hemorrhoids

Breakfast, Lunch, and Dinner Patterns

Pulse - Nadi

Vata Pitta Kapha

Body Temperature - Sparsham

Vata Pitta Kapha

Body Physique - Roopam

Vata Pitta Kapha

Auditory Perception - Shabda

Vata Pitta Kapha

Eyes - Netra

Vata Pitta Kapha

Stool - Pureesha

Vata Pitta Kapha

Urine - Mutra

Vata Pitta Kapha

Tongue - Jihwa

Vata Pitta Kapha

Level of Ama

Low Moderate High

Emotional State

Vata (anxious / restless) Pitta (irritable / intense) Kapha (calm / steady)

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