Ayurvedic Questionnaires

The Ayurvedic Questionnaire is a tool our estheticians use to gather information about your temperment, constitution and lifestyle so we can create customized treatment plans for you each time we see each other. There are three doshas in Ayurveda — Vata, Pitta and Kapha. These doshas correlate with a similar Elemental Nature system where Vata corresponds with Infinity and Air; Pitta is linked with Fire; and Kapha goes with the Water and Earth elements. For more information on this topic, please read my blog post, What is your Elemental Nature? Most people favour one of the three doshas and are out of balance in some way. Our aim at Homespunspa is to help tip the scales to restore balance and harmony to your body, mind and spirit.

NEW and FREE — 30-Minute Elemental Nature Consultations

Homespunspa Mobile Spa is now offering complimentary, no-obligation, 30-minute, face to face consultation appointments to discover your elemental nature and where you might be out of balance to assess which facials and spa treatments would be best for your specific needs. We can meet at the nearest cafe or in your home. Please email us to make an appointment.

In the meantime, please review the questionnaires below.

Below you'll find three questionnaires.

1. The first will help you determine your dosha, which will remain fairly (though not entirely) consistent throughout your life. It's a long form with 31 questions.

2. The second questionnaire, with 15 questions, will build on the first series and will show where you are most out of balance today.

3. The third questionnaire will help you assess your elemental natures and it's a shorter form with 12 questions. To see an example of how the elemental nature system works in terms of skin care recommendations, please read the Homespunspa blog post entitled, Ask Maria About Aveda which I wrote while I was in school.

Questionnaire #1: Determine your dosha, Ayurvedic style

If you'd like to know which dosha you favour most, fill out the first form below and put a check mark next to the statements that best describe you. After you've answered each question, add the checkmarks in the columns together and write your totals in the boxes. The column with the most checkmarks, wins. Feel free to submit your answers to Homespunspa before your next appointment and indicate in the comments if you would like us to forward your results to you. Enjoy.

	Vata	Pitta	Kapha
1. Birth size	My birth size was small.	My birth size was average.	My birth size was large.
2. Body Build	I'm thin and am either short or very tall.	I'm medium in height and body.	I'm tall/sturdy or short/stocky
3. Weight	I have difficulty gaining weight.	I gain or lose weight easily.	I tend to gain weight easily.
4. Fingers and Toes	I have long, tapering fingers and toes.	I have fingers and toes of medium length.	I have square hands and shorter fingers and toes.
5. Joints	I have knobby, prominent joints.	I have well-proportioned joints.	I have large, well-formed joints.
6. Chin and Forehead	I have a delicate chin and small forehead.	I have a moderate chin and a medium forehead that has a tendency toward lines and folds.	I have a large jaw and large forehead.
7. Teeth	I have uneven or buck teeth that are sensitive to either hot or cold.	I have even teeth of medium or small size that tend to yellow.	I have large, white, even teeth.
8. Lips and Mouth	My lips are thin and narrow.	My mouth is of medium size.	My lips are full.
9. Skin	My skin is dry, rough and cold to touch.	My skin is fair, soft and warm to touch.	My skin is pale, cold, and clammy and tends to be oily.
10. Hair	My hair is fine, coarse, brittle and fine-to-medium in texture.	My hair is fine, fair or reddish.	My hair is thick, oily, lustrous and wavy.
11. Neck	My neck is thin and very long or very short.	My neck is of regular proportion.	My neck is solid and strong.
12. Eyes	My eyes are small, narrow or shrunken and my eye colour is dull.	My eyes are of average size and are light coloured.	My eyes are large and lustrous.
13. Shape of Face	The shape of my face is long and angular.	The shape of my face is heart-shaped and I have a pointed chin.	The shape of my face is rounded and full.
14. Tongue	My tongue tends to be dry with a thin gray coating.	My tongue tends to have a yellowish or orange coating.	My tongue tends to be swollen with a thick, white coating.
15. Heat	I have a high tolerance to heat and enjoy hot weather.	I have a low tolerance to heat and enjoy moderate to cool weather.	I have a high tolerance to heat and prefer hot, dry and windy weather.
16. Normal Body Temperature	My normal body temperature is cool and I tend to have cold hands and feet.	My normal body temperature is warm and I often feel too warm or hot.	My normal body temperature is cold.
17. Sleep	My sleep is light and fitful.	My sleep is sound but sometimes disturbed.	I enjoy deep, prolonged sleep.
18. Energy	I have short bursts of energy but my endurance is low and I run out of steam easily.	I have moderate energy, moderate endurance and good reserves.	I have good endurance and large reserves of energy.
19. Perspiration	In heat, I perspire minimally.	In heat, I perspire profusely.	In heat, I get clammy but don't perspire freely.
20. Activity Level	I'm always doing different things. I have a tendency to fidget.	My activity level is focused and moderate.	I can be sluggish and even lazy.
21. Focus	I have a lot of ideas but have difficulty putting them in action. I have a restless imagination.	I'm organized, efficient, intelligent and tend toward perfectionism.	I'm steady, calm and not easily disturbed but do not like to be rushed.
22. Memory	I'm good at remembering recent events but have a poor long-term memory.	I have a good memory.	I absorb information slowly, but once I do absorb it, I have an excellent long-term memory.
23. Strength of Convictions	I'm creative and expressive. I often change my beliefs.	I'm goal-oriented, ambitious and have strong convictions that govern my behaviour.	I'm contented and calm. I have steady, deeply-held beliefs that I will not change easily.
24. Decisiveness	I have difficulty making decisions and change my mind often.	I make rapid decisions and believe that they are good.	I take a long time to make a decision but stick to the choices I make.
25. Routines	I dislike routine and need a lot of change.	I enjoy planning and organizing my life.	I like routines and don't like it when things change.
26. Stress	When stressed, I become fearful, anxious and insecure.	When stressed, I become confrontational, aggressive, judgemental and hot tempered.	When stressed, I have a tendency to withdraw. Sometimes I'm greedy and possessive.
27. Planning	I'm a free spirit. I go with the flow and don't carefully plan my life.	I'm an achiever and I'm ambitious. I carefully plan each step of my life.	I feel safe, steady and calm in my life. I'd prefer it if things remain as they are.
28. On a good day...	On a good day, I'm secure, grounded and settled.	On a good day, I'm confident, warm, brilliant and witty.	On a good day, I'm warm-hearted, loving and active.
29. On a bad day...	On a bad day, I'm cold, distant and insecure.	On a bad day, I'm jealous and controlling.	On a bad day, I'm possessive, lackadaisical and clinging.
30. Friendships	I know a lot of people, but have few close friends.	I have a few good friendships. I seem to make enemies without meaning to.	I have many loyal and close friendships.
31. Money	I spend money impulsively and easily.	I plan how I'll spend my money.	I spend money reluctantly and like to save.
Totals	Vata	Pitta	Kapha
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Questionnaire #2: Indications of Imbalance

If you'd like to know where you fall out of balance, fill out the form below and put a check mark next to the statements that best describe you today. You can pick more than one answer per question, if you wish. After you've answered each question, count the checkmarks in each column and write your totals in the boxes. The column with the most checkmarks will show where you are most out of balance today. I hope you find this interesting. Feel free to submit your answers to Homespunspa before your next appointment and indicate in the comments if you would like us to forward your results to you.

	Vata	Pitta	Kapha
1. Skin	Recently, my skin has been very dry or I have dry patches.	Recently, I have had heat rashes and spots.	Recently, my skin has been oilier than usual.
2. Skin on my face	Today, my skin feels dry and dehydrated.	Today, my skin feels sensitive and irritated.	Today, my skin feels oily and congestive.
3. My primary concerns about my skin is:	Fine lines and signs of aging.	Pigmentation and sensitivity.	Acne breakouts and congestion.
4. Hair	Recently, my hair has been dry and brittle and I have split ends.	My hair seems to be thinning or graying more rapidly than usual.	My hair has been excessively oily lately.
5. Weight	I feel underweight and can't seem to gain weight even though I'm trying.	I keep gaining and losing the same 10 pounds.	I'm overweight and I'm having trouble losing weight.
6. Body Temperature	Lately, I've often felt cold.	These days, I often feel hot and irritated.	Lately, I've been feeling cold and dull.
7. Sleep	I keep waking up and have difficulty getting back to sleep.	I have difficulty getting to sleep, but once asleep, I sleep soundly.	I'm sleeping excessively (9 to 10 hours a night) and I don't want to get up.
8. Energy	I feel exhausted, restless and nervous.	I feel tense and tired but determined to get the job done.	I feel lethargic and have low energy and have difficulty taking on new tasks.
9. Today my Energy Level is:	High but sporadic.	Moderate yet consistent.	Low or sluggish.
10. Today my Anxiety Level is:	High.	Moderate.	Low.
11. Negativity	Lately, I've felt indecisive, chaotic and forgetful and have had difficulty focusing and concentrating.	Lately, I've felt like I'm judgemental of others, overly ambitious and often negative.	Lately, I've felt uninspired and resistant to change and am having trouble retaining information.
12. My stress usually manifests as:	Anxiousness.	Anger.	Withdrawal.
13. Emotional	Today, I'm feeling tearful and anxious.	Today, I'm feeling angry, aggressive and confrontational.	Today, I'm feeling like I want to hide away from the world.
14. I carry most of my tension in my:	Lower back and legs.	Torso and mid-back.	Head neck and shoulders.
15. Today my body feels:	Light and energetic.	Strong and firm.	Heavy and sluggish.
Totals	Vata	Pitta	Kapha
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Questionnaire #3: Determine your elemental nature

If you'd like to know which of the natural elements you favour most, fill out the questionnaire below and put a check mark next to the statements that best describe you today. In this case, you have five choices instead of three. You can pick more than one answer per question, if you wish. After you've answered each question, count the checkmarks in each column and write your totals in the boxes. The column with the most checkmarks, wins. Feel free to submit any or all of these results to Homespunspa.

			Pitta
	Infinity	Air	Fire	Water	Earth
1. The skin type on my face is:	Normal to Dry.	Dry.	Sensitive.	Oily, Acne.	Normal to Oily.
2. My complexion:	is occasionally dull, sometimes burns.	is sallow, matte and burns easily.	Has red undertones, noticable capillaries, always burns.	Has overall shininess, rarely burns.	Is occasionally shiny and burns after long exposure
3. Texture of my skin	is thin and has some dryness, small pores, several fine lines.	is thin, dry and has invisible pores, fine lines	is delicate, soft and smooth and is prone to inflammation and early wrinkles	is soft with some puffiness/water retention, large pores and very few facial lines	is thick, smooth, with medium pores, few wrinkles
4. Challenges include:	Spot dryness and lack of moisture.	Flaky and rough patches.	Prone to irritation, rashes, itchiness and breakouts.	Excess oil, blackheads, whiteheads, acne.	Oily in T-zone, spot blemishes.
5. Body Temperature	Tendency to feel comfortable.	Tendency to feel cold.	Tendency to feel warm/hot.	Tendency to feel cool.	Tendency to feel moderate.
6. My Hair, Scalp	Thin, dull hair with split ends; normal to dry scalp.	Fine hair, possible dandruff, dry scalp.	Fine hair, prematurely grey, sensitive scalp.	Lustrous and oily.	Thick hair, somewhat oily.
7. My Energy Level	Tends to be high.	Is sporadic with a tendency toward extremes.	Is consistent, steady, strong.	Is slow but consistent.	Tends to be low.
8. My response to stress is:	Nervousness.	Anxiousness, worry.	Anger, irritability.	Emotionality.	Withdrawal.
9. My Body Type is:	Usually petite.	Usually tall and thin.	Usually athletic.	Usually heavy.	Usually large and broad-shouldered.
10. My Sleep Pattern:	Sleep light/ awaken easily.	Tend to have frequent insomnia.	Solid sleeper, can function well on less than 6 hours of sleep.	Tendency to sleep deeply, heavily.	Tendency to sleep deeply/heavily, need more than 8 hours.
11. Routines	I mildly dislike routines.	I strongly dislike routines.	I like routines.	I need routines.	I always follow a routine.
12. Thinking Style	I think quickly and often.	I learn new information quickly but forget things easily.	I focus well and have a sharp intellect.	I learn new information slowly.	I have a great long-term memory
Totals	Infinity	Air	Fire	Water	Earth
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Last Name
Email
Appointment Date
Questions or Comments
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