Medical-Astrological and Ayurveda Questionnaire Medical-Astrological Intake QuestionnaireThis questionnaire is a gentle doorway into your physical, emotional, and energetic landscape. The information you share supports your medical-astrological evaluation and helps me trace the patterns that shape your well-being. Thank you for offering your time and presence.Basic Information First NameMiddle NameLast NameDate of birthTime of birth City and country of birthPhysical Health 1, Please share any health conditions you are currently navigating, as well as those you have experienced in the past.2. Is there any part of your body that consistently calls your attention through discomfort or sensations?3. Which elements attracts you the most?– Select –WaterFireEarthAir4. Have you had periods in your life where accidents happened frequently? Yes No5. If you answered Yes, please provide a brief description of the accidents or important physical events you experienced and what year.Mental Health1. Have you gone through periods of depression, emotional heaviness, or anxiety, whether in the present or at earlier stages of your life? Yes No2. If you have gone through these experiences, how frequently have they appeared in your life, whether in the past or in the present?– Select –OccasionallyFrequentlyIn the past — but not anymore3. Do you find yourself repeatedly returning to the same thought? Yes No4. Do you feel that concentrating requires significant effort or slips away easily? Yes NoEmotional Health1. Do you experience challenges when you feel alone or emotionally isolated? Yes No2. Do you experience challenges when trying to build emotional connections with people around you? Yes No3. Do you feel that you naturally move with ease in social spaces and enjoy connecting with others? Yes No4. Have you had thoughts of ending your life? Yes No5. Would you describes yourself as a successful person? Yes No6. Do you find yourself deeply affected by the way others see or interpret you? Yes NoFamily 1. Which family bond influences you most deeply at an emotional level?– Select –FatherMotherBrothersSisters2. Share three (3) transformations you would embrace if life opened the door for them. 3. Do you sense yourself as an integrated and meaningful part of your family circle? Yes No4. Have you experienced moments where you felt left behind or unsupported by your family or a particular family member? Yes No From time to timeRomantic Relationship1. Are you currently in a relationship? Yes No2. If your answer is yes, do you feel fulfilled and at peace within this relationship at this moment in your life? Yes No3. Have you experienced moments in past romantic relationships where you felt left behind or emotionally unattended? Yes No4. Three transformations you would embrace if life allowed you to.Your relationship with your children 1. Do you currently have children? Yes No2. If you answer yes, how many children do you have?3. Do you feel inner tension or anxiety when connecting with them? Yes No4. Mention three changes you would choose to make if you had the opportunity.Work Environment1. Are you presently engaged in any form of work or professional activity? Yes No2. Do you feel fulfilled and at ease within the work you are doing at this moment in your life? Yes No3. Do you experience anxiety when arriving at your workplace? Yes No4. How does the connection with your boss or supervisor feel in your daily work life?5. Do you feel called to transition into a new professional path? Yes NoBody and physical appearance (Ayurveda questions)1. How would you describe your natural body type?– Select –Slim – light buildMedium – well‑proportionedRobust – solid build2. How would you describe your skin?– Select –Dry / slightly roughSensitive / warm / prone to irritationSoft / cool / thick3. How would you describe your appetite?– Select –IrregularStrongSlow, yet steady4. How would you describe your digestion?– Select –Variable / inconsistentFastSlow, yet steady Mental and Emotional State5. How would you describe the movement of your mind?– Select –Quick, creative, and somewhat scatteredFocused, intense, and determinedCalm, steady, and reflective6. How do you manage stress?– Select –Anxiety — a sense of inner tension / worry — the mind leaning toward concernIrritation / frustrationWithdrawal / a sense of slowness7. How would you describe the quality and rhythm of your sleep?– Select –Light / frequently interruptedShort — yet profoundly restorativeLong and heavy-feelingEnergy levels and habits8. How would you describe your energy level?– Select –Shifting / variableHigh, but it depletes quicklyConsistent, but slow9. What is your preferred climate?Warm/ mildCool / fresh-feelingDry / low humidity10. How would you describe your natural rhythm?– Select –Irregular / unevenIntense / high‑energySlow, yet steadyYour natural preferences11. Which flavors do you feel most drawn to?– Select –Salty / sourSpicy / bitter‑tastingSweet / mild12. What kind of activity do you enjoy?– Select –Movement / change-oriented activitiesCompetition / achievement‑oriented activitiesRoutine / calm‑oriented activitiesSubmit the questionnaire
