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Health assessment form

	This is designed to assess your health with the aid of nine steps in the ten folded examination.Carefully go through each heading and put marks which ever matching with you. Dont miss the choices if it is matching Eg; If your skin is oily ,cold, smooth ,soft and white put marks on all these 5 choices. If none of them are matching leave that heading and go to the next one. As the information you submit here are personal in nature,This form and all related information will be accessible only to ourto our panel of doctors who will treat it strictly confidential.
	Main reason for consultation: Treat ment for rejuvenation: Ailments: Reducing weight: Purification: Others:

	Register Number Name Age Male Female Height Weight Permanent address E-mail Address Occupation Marital Status Children

1. BODY SKIN

SmoothRough	ColdWarm
DryOily	White YesNo
Pinkish(espiecially palm & sole) YesNo	Soft Yes No
Clear Yes No (Whether your skin got a uniform colour without patches?)	Lustrous Yes No (Do you have a shining/glowing skin?)
Very attractive Yes No	Cracked Yes No
Moles & acne Yes No (Do you have many moles & acne on your body?)

2. HAIR OF THE BODY

Short Long	Baldness Yes No
OilyDry	Wavy Yes No
ThinThick	Few hairs Yes No
Dark Grey or red colouredWhite	Lustrous Yes No (Do you got shining and glowing hair on your body)
Soft and FineCoarse (Whether your hair lack softness, fineness & delicacy)
Deep Rooted Yes No

3. Eyes

SmallMedium size Large	Piercing Yes No (Do you have deep penetrating eyes?)
Prominent Yes No (Do you have eyes which projects or bulges out)	Stable Yes No (Do you have fixed & steady eyes?)
Red Coloured White (as if filled with milk) Brownish	Unctuous Yes No (Do you have smooth, soothing & comforting eyes?)
Thick eye lashes.Few eye lashes
Charming and Radiant Appearance Yes No (Do you have bright, pleasing & attractive eyes?)
Beautifully covered with muscles Yes No

4. FACE

Red Coloured Yes No
( especially cheeks, ear lobes,nostrils & fore head.)

Charming and radiant appearance Yes No
(Do you have a bright, pleasing & attractive face?)

5. TONGUE

Red Coloured Yes No

6. LIPS

Oily Dry	Red coloured Yes No
Small Medium Large	Charming and radiant appearance Yes No (Do you have a bright, pleasing & attractive lips?)
ThickThin
Soft Yes No

7. NAILS

Oily (smooth) Dry(rough)	Red Coloured Yes No
SmallMedium Large	White coloured Yes No
ThinThick	Charming & radiant appearance Yes No (Do you have a bright, pleasing & attractive nails?)
StrongSoft	Prominent Yes No

8.FOREHEAD & TEMPLES

Small Medium size Broad & large

Well covered with muscles Yes No
(The bony prominences are not visible)

9. PALATE

Red Coloured Yes No

10. NECK.

Firm Yes No
(Do you have a stable, steady & elastic neck?)

Prominent Yes No
(Do you have a neck which stands out?)

muscular Yes No
(Do you have well defined muscles in your neck?)

11. CHEEKS

Firm Yes No
(Do you have possess stable, fixed & elastic cheeks?)

Prominent Yes No
(Do you have cheeks which bulge out?)

12. CHIN

Firm Yes No (Do you have a stable, steady & fixed chin?)	Well covered with muscles Yes No (The bony prominences are not visible)
Prominent Yes No

13.SHOULDERS

Firm Yes No	Muscular Yes No (Do you have well defined muscles on your shoulders?)
Prominent Yes No	Large size Yes No

14. ABDOMEN

Firm Yes No	muscular Yes No (Do you have well defined muscles on your abdomen?)
Prominent Yes No

15. CHEST

Firm Yes No	muscular Yes No (Do you have well defined muscles on your chest?)
Prominent Yes No

16. JOINTS OF THE UPPER LIMB

Firm Yes No (Do you have possess stable, steady & well fixed joints on your upper limb?)	Well covered with muscles Yes No (Bony prominences are not visible)
Prominent Yes No (Do they stand out?)	Rounded Yes No (Are the joints round in shape?)

17. JOINTS OF THE LOWER LIMB

Firm Yes No	Well covered with muscles Yes No
Prominent Yes No	Rounded Yes No

18. VOICE

High pitchedLow pitched (Does your sound got a sharp tone?)	Melodious Yes No (Do you have a rhythemic & harmonious voice?)
ClearWeak	Hoarse Yes No
Unctous Yes No (Do you have a smooth, soothing & comforting sound/voice?)	Deep tone Yes No
Resonant Yes No (Does your voice prolongs by reflexion?)

19. TEETH

Strong Weak	Close to each other Yes No
Rounded Pointed	WhiteYellowish
Firm Yes No (Are they well fixed with the sockets & gums?)
Ordered Yes No (Are the teeth arranged in a uniform level?)

20. URINE

Colourless WhitishYellowish	Scanty(not clear)Clear
Unctous Yes No (Do you have smooth urination?)

21. SWEAT

No smellStrong smell Pleasant smell	Oily Yes No (Is your sweat sticky?)
Moderate sweatingProfuse sweating

22. FAECES

Unctuous (smooth,oily) Dry & hard	Intermittent diarrhoea Yes No
Regular bowelsIrregular bowels. (Is the habit of excretion of feaces/habit of defecation regular/irregular?)	Musous discharge Yes No (Is there any slimy viscous discharge during defecation?)
ConstipationSolid stools Loose

23. BODY

Good strength / PowerMedium strength Less strength	Slow in starting Yes No
Well built Yes No	Starts & stops work quickly Yes No
Firm Yes No (Do you have a stable & steady body?)

24. BONES (especially collar bones, chin & heels)

Prominent Yes No (Do you possess bones which stands out so that they are easily visible?)	Strong Yes No
Well covered with muscles Yes No	Covered with fat Yes No

General Attributes

25. Softness /Suppleness of body Yes No

26. Not lean and thin Yes No

27. Large buttocks Yes No

28. Large & prominent head Yes No

29.Slow aging process Yes No
(Whether you look younger than the real age and have fresh appearence & vigour?)

30. Intolerance to heat Yes No

31.Firm & well arrayed movement Yes No
(Whether all the movements are stable, steady & properly placed?)

32. Resistance to the diseases
a. Weak, variable b. Medium, prone to infections c. Good, consistant, strong

33. Inefficiency to do physical labour Yes No

34.Appetite
a. Appetite is variable b. Strong appetite, irritable if you miss a meal
c. Constant appetite ,can skip meals easily.

35. Progeny Yes No
(Do you have children?)

36. Excessive sexual desire Yes No

37. Good fortune Yes No

38. Intelligence Yes No

39. Knowledge Ignorence

40. Cheerfulness Yes No
( Are you happy & joyful?)

41. Mental Power Yes No

42. Mental tranquility Yes No
(Do you have peace of mind?)

43. Delicate behavior Yes No

44. Lack of endurance Good endurance Medium endurance
(Endurance = Power of bearing and suffering problem)

45. Dreams while sleepYes No

46. Pleasing nature Yes No

47. Patience Yes No

48. Command Yes No

49. Lack of greed Yes No

50. Simplicity Yes No

51. Very enthusiastic Yes No

52. Active Yes No

53.good memory Yes No

54. Devotion Yes No
(Do you have dedication/attachment to your work, friends etc.,?)

55. Acknowledgment & Gratitute to past services Yes No

56. Skill
a. Human Skill b. Technical Skill c. Conceptual skill

57. Courageous in combating Yes No

58. Absence of sorrow Yes No

59.Attracted by opposite sex Yes No

60. Virtuous acts Yes No
(Do you act with moral excellence, goodness & high righteousness?)

61. Self confidence in all enterprises Yes No

62.Happiness Yes No

63. Children with similar qualities Yes No

64. Wealth Yes No

65. Pleasing look Yes No

66. The tastes you like most
a. Sweet b. Sour c. Salty d. Bitter e. Pungent f. Astringent

67.
a. Spends money quickly b. Spends money on luxuries c. Saves money

68.
a. Difficulty in making decisions b. Quick in making decisions, strong minded
c. Slow in making decisions & actions.

69.Social dignity and respect Yes No

70.
a. Quick, inconsistant irratic speech, talkative b. Moderate, convincing speech, argumentative
c. Slow definite speech, not very talkative.

71.
a. Fearful, anxious & nervous b. Angry & irritable in emotions
c. Sentimental, calm, attached in emotions

72.
a. Light, disturbed sleep b. Moderate sleep, may wake up & fall asleep
c. Heavy sleep ,difficulty in waking up

Physical power

You should mention about your body strength in general
• Are there some conditions in which you feel weak or strong?

• Which kind of weather bothers you the most?

• Which part of the day or night do you feel the strongest?

• How many hours you work daily?

• Do you exercise regularly?

• What kind of exercises do you do and how often?

• At what time of the day do you usually exercise and what are the surroundings?

• How do you feel after exercise?

• Any other details?

Mental nature and the nervous system

• Are you always in tension, anxiety or stress and what causes this? Is it related to some diet, activity or climatic condition?

• How is your sleep? Is it sound sleep / disturbed?

• How many hours do you usually sleep? Please mention the timings of going to bed and waking up.

• Do you think your disease has some relation to your being nervous, stressful, fearful, anxious etc? Do you find any change in the symptoms under such conditions?

Whether the following matches with you or not ?

Desires equality of all creaures Yes No

Hospitality, Studying scriptures Yes No
(Friendly reception & treatment of friends & strangers)

Lordship, Authoritative speech Yes No
(State/dignity of a lord, speech substantiated with evidence / proof)

Readiness for initiation of action Yes No

Fond of aquatic sports Yes No

Possession of luxuries, attendents ,power & wealth Yes No

Fond of music, dance, perfumes, desirous of opposite sex Yes No

Aversion towards violence Yes No

Sharing mentality Yes No

Forbearance Yes No
(Patience or self control when subjected to provocation)

Truthfulness Yes No

Righteousness Yes No

Belief in God Yes No

Spiritual knowledge Yes No

Intellect Yes No

Good memory Yes No

Comprehension Good deeds and helpfulness. Yes No
(Understanding acts & performance)

Boasting, cruelty, envy Yes No
(Jealously, regard to anothers sucess, advantage)

Exploiting others at their weak points. Yes No

Unclean / bad food habits, likes to be with opposite sex in secret places. Yes No

Sharp reaction, arouses fear in others Yes No

Sorrow indolence Yes No
(Indolence = Lazziness)

Passion / lust Yes No

Grief Yes No

Non comprehension Yes No

Vanity Yes No
(Excessive pride in ones appearence, qualities, achivements)

Absence of truthfulness Yes No

Nonclemency Pride Yes No
(Not forgiving, not mild)

Excessive self confidence Yes No

Anger Yes No

Forbidding nature, hateful conduct and food habits. Yes No
(Unfriendly)

Unsteadiness, fond of movements and water.Yes No

Lack of intelligence Yes No

Despondency Yes No
(Discouragement, hopeless)

Stupidity Yes No

Ignorence Yes No

Wickedness Yes No
(Quality of immoral evil acts)

Lethargy Yes No
(Drowsyness, sluggishness, dullness)

Sleepiness Yes No

Sorrow Yes No

Fear Yes No

Appetite, Diet & Habituation
. Do you eat heavily or not ? Whether the food get digested easily ?

• Do you have problems like heaviness, feeling weak and lethargic immediately after eating?

• Do you have any pain in the stomach area, specially after eating or on empty stomach? If yes, specify the area of pain.

• Do you have wind or gas?

• Do you over-eat?

• What kind of foods bother you and which ones are OK? What kind of trouble do you have, explain in details.

• Do you often have acid formation, burping (with or without acid) or burning in the stomach?

• Any other information, that you would like to give?

It would be nice if you describe your diet in your own language. You can take some help form the following questions, if you are not able to explain the diet.
Kinds of food usually taken:
Breakfast
Lunch
Dinner

• Are you vegetarian? If no, how often you eat meat, fish or other kind of non-vegetarian foods.

• Do you take snacks/foods in between your main meals? If yes, what?

• Quantity of tea, coffee, alcohol, or any other kind of drinks taken in a day?

• How often do you eat fast foods, fried foods, frozen foods and foods that have been microwaved?

• How much water do you usually drink in a day?

• Quantity of milk products and sweets and their kinds?

• Addiction to any ill healthy habits?

Now go to the Diagnosis questionnaire if you have any ailments or if the health assesment form was not sufficient to describe you.