PRE CONSULTATION QUESTIONNAIRE
Thank you for choosing Sitaram Beach Retreat for your health solutions. For better understanding of your health and to serve you well. we need some information, kindly spend a few time answering the following questions.

1. What improvements to your body and mind do you expect from Sitaram Beach Retreat?

2. What is the one thing if it could change everything else will get better in life?

3. Please describe the nature of your work? Does it include too much computer work, too much travels? Do you like to eat outside regularly because of travels?

4. How much satisfied are you with your sleep? (rate out of 5 ; where 5/5 is the most satisfied level.)

1/5 2/5 3/5 4/5 5/5

5. Do you find difficulty to fall sleep at night?

Yes NO

6. Do you feel lack of energy at any particular period of time?

7. How would you rate the energy levels in the morning?

1/5 2/5 3/5 4/5

8. How would you rate the energy levels in the noon?

1/5 2/5 3/5 4/5

9. How would you rate the energy levels in the night?

1/5 2/5 3/5 4/5

10. How good is the digestion ?

Satisfactory Non-Satisfactory Needs improvement

11. Kindly specify your body physique

A B C
Body size Slim Medium Large
Body weight Low Medium Over weight
Chin Angular Tapering Rounded
Cheeks Wrinkled sunken Smooth flat Round plump
Eyes Small, sunken, dry, black Sharp, bright, gray Big, beautiful,calm
Nose Uneven shape, deviated septum Long pointed, red nose_tip Short rounded
Lips Dry, craked, black/brown tinge Red, inflamed,yellowish Smooth, oily, pale,whitish
Teeth Big, thin gums Medium, soft, tender gums Healthy, white, strong gums
Skin Thin, dry, cold, rough, dark Smooth, oily, warm Thick, oily, cool, white, pale
Hair Dry brown, black, knotted, brittle, scarce Straight, oily, gray, bald Thick, curly, wavy, luxuriant
Nails Dry, rough, brittle, break easily Sharp, flexible, pink, lustrous Thick, oily, smooth, polished
Neck Thin, tall Medium Big, Folded
Chest Flat, sunken Moderate Expanded, round
Belly Thin, flat, sunken Moderate Big, pot-bellied
Belly- button Small, irregular, herniated Oval, superficial Big, deep, round, stretched
Hips Thin Moderate Heavy, big
Joints Cold, cracking Moderate Large, lubricated
Appetite Irregular, scanty Strong, unbearable Slow but steady
Digestion Irregular, forms gas Quick, causes burning Prolonged, forms mucous
Taste Sweet, sour salty Sweet,bitter, astringent Bitter, pungent, astringent
Thirst changeable Surplus sparse
Score
Mental activity Hyperactive Moderate Dull, slow
Emotions Anxiety, uncertainty Anger, hate, jealousy Calm, greedy, attachment
Faith variable extremist consistent
Intellect Quick but faulty response Accurate response Slow, exact
Recollection Recent good, remote poor Distinct Slow and sustained
Dreams Quick, many, fearful Fiery, war, violence Lakes, snow, romantic
Sleep Scanty, broken up, sleepness Little but sound Deep, prolonged
Speech Rapid Sharp, penetrating Slow
Score

12. How many times you have a meal each day?

One Two Three Several

13. Do you feel hunger before each meal?

Too much Normal Less

14. After a meal you feel

Heavy stomach Burning sensation Nausea Feels to go to toilet Pain in stomach

15. How often do you go to toilet?

Once/twice every day Frequently Constipated most of the days any special personal routine

16. How does your stool looks like?

  • Bristol Stool Chart

  • Type1
    Seperate hard lumps,like nuts (hard to pass)
  • Type2
    Sausage-shaped but lumpy
  • Type3
    Like a sausage but with cracks on its surface
  • Type4
    Like a sausage or snake, smooth and soft
  • Type5
    Soft blobs with clear-cut edges (passed easily)
  • Type6
    Fluffy pieces with ragged edges, a mushy stool
  • Type7
    Watery, no solid pieces. Entirely Liquid

17. Have you ever noticed after taking milk / sugarcane juice of any laxatives. Your bowel movements was

more than 3 times less than 3 times

18. Have you ever felt dehydrated after taking any medicines?

Yes No

19. Have you undergone any treatments before?

Yes No

20. What type ?

Ayurveda Allopathic medicines Allopathic surgical Other system of medicine

21. Are you presently under going any medication?

Yes (Specify :) No

22. Have you ever diagnosed with a Hormone problem?

Yes No

23. Have you ever diagnosed with high blood pressure?

Yes No ( If you remember the last Blood pressure value : )

24. Have you checked your blood sugar level?

No Yes, normal Yes, found diabetic

25. Have you ever diagnosed with any cardiac problems?

Yes No

26. Have you checked your blood recently and found any abnormalities in any tests?

Specify:
Test Value Normal Value

27. Are you allergic to?

Dust Medicine ( Specify : ) Food items( Specify : )

28. Are you addicted to

Smoking (Frequency:/day) Alcohol (Frequency: /day) Drugs Tobacco Coffee / tea

29. Menstrual History ( only for female guests)

1) At what age your first menstruation started?

Below 12 years In between 12 & 15 years Above 15 years

2) How is your menstrual cycle?

Regular Irregular Duration Cycle days
Painful Scanty Moderate Heavy

3) Last Menstruation date:

4) Do you feel any relation for your illness with menstrual cycle?

Yes No
Specify:

5) What is your mental status before, during and after menstruation?

Normal Abnormal
Before
During
After

6) Do you have any children?

Yes No Abortion Miscarriage

7) How was your delivery?

Normal Abnormal
First Delivery
Second Delivery
Third Delivery
Fourth Delivery

8) Have you noticed any new symptoms arising after your delivery?

Yes No

9) Are you in menopause? Any Symptoms?

Yes No
Symptoms:
I affirm that I have read the disclaimer and comply with the same. Further, I affirm that the nature and purpose of the treatments, the risks involved and the possibility of complications have been fully explained to me. No guarantee or assurance has been given to me by anyone as to the results that may be obtained.