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Ayurvedic Questionnaire for the Assessment of Prakriti & Vikriti

According to Ayurvedic knowledge & practice, the Prakriti is the baseline


Constitution of an individual, while the Vikriti is the manifestation of a
particular complaint, which can be seen on the surface, relating to what may
be an acute or chronic condition.
Ayurveda aims to heal the complaints of Vikriti by removing the causal factors
through lifestyle changes, alongside herbal therapy. This approach naturally
brings balance to the individuals core constitution, the Prakriti.
When we are in harmony with the principles of our Prakriti (nature) - with what
naturally keeps us in balance- then the outcome is good health & an overall
sense of well-being.
The answers to these questions will provide an outline that serves as a way to
determine the causes of your condition. With such causes in view, we will be
able to suggest the appropriate actions needed to achieve balance & wellness.
*Without having an individual present- to listen to the pulse & read the tongue
along with other physical signs- it is hard to establish the exact Prakriti Dosha.
*Never-the-less, such a questionnaire could reveal signs & clues as to what
needs to be worked on in order to bring harmony to ones true nature.
Please add anything that pertains to your chief concern & what you would like
to address immediately.
*in reference to long distant clients

Client Information

Name: ____________________________
Address: _____________________________ Phone: ______________
Email: _____________________ Vocation/Occupation:
_________________
Chief Mind-Body concern to address:
______________________________

Questionnaire:
Please provide detailed answers to the following questions:
1.) What is your age? ________

2.) How well do you digest food? Does it take a long time? Are there any

complaints?

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3.) What is the frequency of your elimination (evacuation & urination)?

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4.) Whats the consistency of your wastes (urine & fecal matter)?

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5.) Does it take much to work up a sweat?

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6.) Are you currently taking any herbs or medications for any reasons? If so,

please list them accordingly.

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7.) What is your sleeping pattern?

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8.) What are the patterns of your overall energy levels?

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9.) How do you feel upon waking?

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10.) Do you require an afternoon nap?

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11.) How is your endurance & stamina during activities?

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12.) How is your libido?

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13.) How well does your immune system function?

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14.) Are there any chronic pains or complaints of weaknesses or


dysfunctions in the body?

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16.) What is the mental state youre generally in?

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17.) What is the emotional state that youre normally in?

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18.) What type of impressions do you enjoy in your free time


(entertainment, company, fun & pastimes)?

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19.) Do you have a spiritual/meditation practice (sadhana)?

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20.) Are you fulfilled with your life; your chosen career/life path?

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21.) What is the main health concern that you would like to address
through Ayurvedic methods?

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