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Dosha Imbalance Questionnaire

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What Dosha Needs Attention?

Those who are new to Ayurveda are often puzzled about how to get started. It's actually not that complicated. The first priority is to reduce Ama if excessive and resolve indigestion. Along the way it always helps to improve habits. The next priority is to balance the Doshas. This brief questionnaire will help you identify which Dosha is most likely to be causing current symptoms.

This brief questionnaire will characterize the quality of your digestion and highlight any imbalances. I ask all Clients to complete it as an adjunct to their consultation. It supplements the pulse reading and responses to the other questionnaires.

Instructions for Completing the Dosha Imbalance Questionnaire

  • Respond to every item.
  • Please enter your email. That way you will receive a copy of the report.
  • I welcome your comments and suggestions for improvement.
  • All information entered here will be kept confidential according to my Privacy Policy.

Dosha Imbalance Questionnaire

When selecting your responses, think about what is most generally true about you at the present time.

Body-Related Items
Please indicate the degree to which the following statements apply to you Strongly Disagree Disagree Somewhat Disagree Neutral Somewhat Agree Agree Strongly Agree
I'm suffering from dry skin 1 2 3 4 5 6 7
I have trouble with inflammation 1 2 3 4 5 6 7
I feel lethargic too much of the time 1 2 3 4 5 6 7
I have burning sensations in my body 1 2 3 4 5 6 7
I suffer with body pains 1 2 3 4 5 6 7
My skin is excessively oily 1 2 3 4 5 6 7
I often have a sweet or salty taste in my mouth 1 2 3 4 5 6 7
I'm craving more warmth 1 2 3 4 5 6 7
I have trouble with my eyes 1 2 3 4 5 6 7
I'm bothered by heat 1 2 3 4 5 6 7
I have a nagging dry cough 1 2 3 4 5 6 7
I feel too heavy 1 2 3 4 5 6 7
My throat is too dry 1 2 3 4 5 6 7
I have trouble with body odor 1 2 3 4 5 6 7
I'm having joint problems 1 2 3 4 5 6 7
I have trouble gaining weight 1 2 3 4 5 6 7
I'm bothered with sinus congestion 1 2 3 4 5 6 7
I feel fatigued too much 1 2 3 4 5 6 7
I've lost my interest or ability to enjoy sex 1 2 3 4 5 6 7
I wish I had more energy 1 2 3 4 5 6 7
Headaches are a problem for me 1 2 3 4 5 6 7
I have skin rashes 1 2 3 4 5 6 7
I often cough up phlegm 1 2 3 4 5 6 7
I've put on too much weight 1 2 3 4 5 6 7
Mind-Related Items
Please indicate the degree to which the following statements apply to you Strongly Disagree Disagree Somewhat Disagree Neutral Somewhat Agree Agree Strongly Agree
I feel sad too much of the time 1 2 3 4 5 6 7
I feel discontented 1 2 3 4 5 6 7
I'm overly critical of others 1 2 3 4 5 6 7
My mind is buzzing with too many thoughts 1 2 3 4 5 6 7
I'm angry too often 1 2 3 4 5 6 7
I find myself caught up in hate 1 2 3 4 5 6 7
My heart feels broken 1 2 3 4 5 6 7
I've become too greedy 1 2 3 4 5 6 7
I'm bothered by jealousy 1 2 3 4 5 6 7
My habit of procrastination is causing me trouble 1 2 3 4 5 6 7
I'm troubled by fear 1 2 3 4 5 6 7
I'm too impatient 1 2 3 4 5 6 7
My sexual desire has become excessive 1 2 3 4 5 6 7
I've lost my sense of generosity 1 2 3 4 5 6 7
I worry too much 1 2 3 4 5 6 7
I frequently wake up in the middle of the night and have trouble getting back to sleep 1 2 3 4 5 6 7
I have a lot of trouble falling asleep 1 2 3 4 5 6 7
I want to sleep too much 1 2 3 4 5 6 7
I've become too irritable 1 2 3 4 5 6 7
I have trouble forgiving others 1 2 3 4 5 6 7
I'm bothered by anxiety 1 2 3 4 5 6 7
Required Supportive Information

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Comments

Do your responses reflect your situation and represent permission to use your de-identified data in aggregate scientific studies? Clients should be able to comfortably answer yes. If not, please call to discuss.

For clients and prospective clients only: Do you wish to send a copy of your report to Elianne van Waalwijk van Doorn?