Dosha Analysis Questionnaire

Select one answer for each row: the option which you have observed to be the most consistent over a long period of time or growing up. Input from a parent or spouse can be very helpful in accurate analysis. Add the number of answers in each column

Name		Date
Email

	Vata - AIR	Pitta - FIRE	Kapha - EARTH
Body Frame	Slim	Medium	Large
Body Weight	Low	Medium	Overweight

Eyes	Small, active	Sharp, sensitive	Large, beautiful
Nose	Crooked, sharp	Long, pointed	Short, round
Lips	Dry, cracked	Red, inflamed	Smooth, oily
Cheeks	Wrinkled, sunken	Smooth, flat	Plump, rounded
Teeth	Large, thin gums	Tender gums	White, strong gums

Skin	Dry, cold, rough	Warm, rosy, oily	Cool, oily, thick
Hair	Dry, brittle, scarce	Straight, oily, bald	Thick, curly, oily
Nails	Rough, dry, brittle	Sharp, flexible,pink	Thick, oily, smooth

Neck	Long, thin	Medium	Large, folded
Chest	Flat, sunken	Medium	Expanded
Belly	Flat, sunken	Medium	Pot belly
Hips	Slender	Medium	Heavy
Joints	Cold, cracking	Medium	Large, lubricated

Appetite	Irregular, scant	Strong, unbearable	Slow, steady
Thirst	Irregular	Surplus	Little
Digestion	Irregular, bloating	Quick, burning	Prolonged
Bowel Habits	Constipation	Loose stools	Thick stools,sluggish

Physical Activity	Hyperactive	Moderate	Slow
Mental Activity	Hyperactive	Moderate	Slow

Emotions	Anxiety, fear	Anger, jealousy	Calm, possessive
Faith	Variable	Extremist	Consistent
Intellect	Quick, incorrect	Accurate, sharp	Slow and steady
Memory	Poor remote	Distinct	Slow and sustained]

Disease	Pain, Autoimmune, Arthritis, Palpitations	Fever,Inflammation,Migraine, High BP	Overweight,Diabetes, Congestion
Dreams	Fearful	Violent	Romantic
Sleep	Scanty, broken	Little, sound	Prolonged, deep
Speech	Rapid, unclear	Sharp, penetrating	Slow, monotonous
Finances	Spends on trifles	Spends on luxuries	Saves money

A practice of Integrative and Holistic Medicine

Dosha Analysis Questionnaire