This is a sample form. To avail doctor consultation Click here to Pay and Complete Health Assessment Form

Health assessment form


This is designed to assess your health status with the aid of nine steps in the ten folded examination.Carefully go through each heading and click whichever matches you the best.

As the information you submit here are personal in nature,this form and all related information will be accessible  only to our panel of doctors who will treat it strictly confidential.

Main reason for consultation:

Treat ment for rejuvenation:
Reducing weight:


Register Number            



Sex                                  Male Female



Permanent address  & Tel No     

E-mail Address              


Marital Status                

Children - No and gender

SmoothRough               ColdWarm
DryOily Fair YesNo
Pinkish(especially palm & sole) YesNo Soft   Yes No     
Clear Yes No
(Whether your skin has a uniform colour without patches?)
Lustrous  Yes No
(Do you have a shining/glowing skin?)
Very attractive Yes No Cracked Yes No
Moles & acne Yes No 
(Do you have many moles & acne?)        
Short Long Baldness Yes No
OilyDry Wavy Yes No
ThinThick Few hairs Yes No
Dark Red colouredGrey Lustrous Yes No
(Do you have shining and glowing hair on your body)
Soft and FineCoarse
(Whether your hair is delicate or lack softness & fineness)
Deep Rooted  Yes No
   3. Eyes
SmallMedium size  Large Piercing  Yes No
(Do you have deep penetrating eyes?)
Prominent Yes No
(Do you have eyes which projects or bulges out)
Stable Yes No
(Do you have fixed & steady eyes?)
Red Coloured White (as if filled with milk)
 Brownish (White portion of the eyes[sclera])
Unctuous Yes No
(Do you have smooth, soothing & comforting eyes?)
Thick eye lashes.Few eye lashes   
Charming and Radiant Appearance Yes No
(Do you have bright, pleasing & attractive eyes?)
Well covered with flesh Yes No
Red Coloured Yes No
( especially cheeks, ear lobes,nostrils & fore head.)
Charming and radiant appearance Yes No
(Do you have a bright, pleasing & attractive face?)
   5. TONGUE
Red or   coppery coloured Yes No
Oily Dry Red coloured  Yes No
Small Medium Large Charming and radiant appearance Yes No
(Do you have bright, pleasing & attractive lips?)
Soft Yes No
  7. NAILS
Oily Dry Red Coloured Yes No
SmallMedium Large White coloured Yes No
ThinThick Charming & radiant appearance Yes No
(Do you have   bright, pleasing & attractive nails?)
StrongSoft Prominent Yes No
Small Medium size Broad & large
Well covered with flesh   Yes No
(The bony prominences  are not visible)
Red Coloured Yes No
10. NECK.
Firm Yes No
(Do you have a stable, steady & elastic neck?)
Prominent Yes No
(Do you have a neck which stands out?)
muscular Yes No
(Do you have well defined muscles on  your neck?)
Firm   Yes No
(Do you have   stable, fixed & elastic cheeks?)
Plumpy cheeks Yes No
(Do you have cheeks which bulge out?)
12. CHIN
Firm Yes No
(Do you have a stable, steady & fixed chin?)
Well covered with flesh  Yes No
(The bony prominences are not visible)
Prominent Yes No
Firm Yes No Muscular Yes No
(Do you have well defined muscles on your shoulders?)
Prominent Yes No Broad shoulders Yes No
Firm Yes No Muscular   Yes No
(Do you have well defined muscles on your abdomen?)
Prominent Yes No
Firm Yes No  Muscular Yes No
(Do you have well defined muscles on your chest?)
Prominent Yes No 
Firm   Yes No
(Do you possess   steady, firm & fully mobile joints)
Well covered with muscles Yes No
(Bony prominences are not visible)
Prominent Yes No 
(Do your shoulder, elbow & wrist joints  stand out?)
Rounded Yes No
(Are the joints round in shape?)
Firm Yes No  Well covered with muscles Yes No 
Prominent Yes No 
(Do your knee and ankle joints stand out)
Rounded Yes No 
High pitchedLow pitched
(Does your sound got a sharp tone?)
Melodious Yes No
(Do you have a rhythmic & harmonious voice?)
ClearWeak Hoarse Yes No
Unctuous   Yes No 
(Do you have a smooth, soothing & comforting sound/voice?)
Deep tone Yes No
Resonant Yes No 
(Does your voice resonate in your head while speaking ?)
Strong Weak Close to each other Yes No
Rounded Pointed WhiteYellowish
Firm Yes No 
(Are they well fixed in  the sockets & gums?)
Ordered Yes No 
(Are the teeth arranged in a uniform orderly manner?)
Colourless WhitishYellowish UnclearClear
Unctuous  Yes No 
(Is your urinary flow contineous/interrupted?)
No smellStrong smell Pleasant smell Is your sweat sticky Yes No 
Moderate sweatingProfuse sweating
Smooth & easy passing of bowels Dry & difficult bowel passing Intermittent diarrhoea  Yes No 
Regular bowelsIrregular bowels.
(Is the habit of excretion of feaces regular / irregular?)
Mucous discharge Yes No 
(Is there any slimy viscous discharge during defecation?)
ConstipationSolid stools  Loose stools
23. BODY
Good strength / PowerMedium strength  
Low strength
Slow in starting Yes No 
Well built Yes No  Starts & stops work quickly Yes No
Firm Yes No 
(Do you have a stable & steady body?)
24. BONES (especially collar bones, chin & heels)
Prominent Yes No 
(Do you possess bones which stand out & are easily visible?)
Strong Yes No 
Well covered with muscles Yes No  Well covered with fat Yes No 
General Attributes
25. Soft  / Flexible / Supple body   Yes No 
26. Not lean and thin Yes No 
27. Large buttocks Yes No 
28. Large & prominent head Yes No 
29.Slow aging process Yes No 
(Whether you look younger than your real age and have fresh appearance & vigour?)
30. Intolerance to heat Yes No 
31. Firm & well arrayed movement Yes No 
32. Resistance to the diseases
      Weak, variable
     Medium, prone to infections   Good, consistent, strong
33. Inefficiency to do physical labour Yes No 
Appetite is variable   Strong appetite, irritable if you miss a meal
  Constant appetite ,do not feel weak if a meal is skipped.
35. Progeny Yes No 
(Do you have children?)
36. Excessive sexual desire Yes No 
37. Good fortune Yes No 
38. Intelligence Yes No 
39. Knowledge Ignorance 
40. Cheerfulness Yes No  
( Are you happy & joyful?)
41. Mental Power Yes No 
( Ability to remain calm under adverse situations)
42. Mental tranquility Yes No 
(Do you have peace of mind?)
43. Delicate behavior Yes No 
( Easily upset and feel hurt over situations)
44. Lack of endurance   Good endurance Medium endurance
(Endurance is the ability to bear suffering & pain)
45. Dream during sleepYes No 
46. Pleasing nature Yes No 
( Able to make friends easily)
47. Patience Yes No 
48. Command Yes No 
( Ability to command others)
49. Lack of greed Yes No 
50. Simplicity Yes No 
( Is a simple way of living satisfying to you?)
51. Very enthusiastic Yes No 
52. Active Yes No 
( Mentally very active )
53.Good memory Yes No 
54. Devotion Yes No 
(Do you have dedication / attachment to your work, friends etc.,?)
55. Always acknowledge & have gratitude for help received Yes No 
56. Skill
  Human Relation Skill Technical & Managerial Skill Conceptual skill
57. Courageous in combating Yes No 
58. Absence of sorrow Yes No 
59.Attracted by opposite sex Yes No 
60. Virtuous acts Yes No 
(Do you act with moral excellence, goodness & high righteousness?)
61. Self confidence in all enterprises Yes No 
62.Happiness Yes No 
63. Children with similar qualities Yes No 
64. Wealth Yes No 
65. Pleasing look Yes No  
66. The taste you like most
Sweet Sour Salty Bitter Pungent Astringent 
Spend money quickly Spend money on luxuries   Save money
  Difficulty in making decisions   Quick in making decisions, strong minded
  Slow in making decisions & actions.
69.Social dignity and respect Yes No 
  Quick, inconsistent erratic speech & talkative   Moderate, convincing speech, argumentative
  Slow definite speech, not very talkative.
  Fearful, anxious & nervous   Angry & irritable in emotions
  Sentimental, calm, attached with emotions
  Light, disturbed sleep    Moderate sleep, may wake up & fall asleep
  Heavy sleep ,difficulty in waking up
Physical power

You should state your body strength in general
• Are there some conditions in which you feel weak or strong?

• Which kind of weather bothers you the most?

• Which part of the day or night do you feel the strongest?

• How many hours do you work daily?

• Do you exercise regularly?

• What kind of exercises do you do and how often?

• At what time of the day do you exercise and in what surroundings?

• How do you feel after exercise?

• Any other information you wish to share?



Mental nature and the nervous system

• Are you always in tension, anxiety or stress and what causes this? Is it related to some diet, activity or climatic condition?

• How is your sleep? Is it sound sleep / disturbed?

• How many hours do you usually sleep? Please mention the timings of going to bed and waking up.

• Do you think your disease has some relation to your being nervous, stressful, fearful, anxious etc? Do you find any change in the symptoms under such conditions?


Whether the following matches with you or not ?

Desire equality of all human beings Yes No 
Hospitality Yes No 
(Friendly reception & treatment of friends & strangers)
Authoritative speech Yes No   
(Stateliness & authority  evidenced by way of speech)
Readiness for initiation of action Yes No   
Fond of aquatic sports Yes No 
Possess   luxuries, attendents ,power & wealth Yes No 
Fond of music, dance, perfumes Yes No 
Aversion towards violence Yes No  
Sharing nature Yes No  
( Will to share)
Forbearance Yes No 
Truthfulness Yes No 
Righteousness Yes No 
Belief in God Yes No  
Spiritual knowledge Yes No 
Intellect Yes No 
( High thinking power)
Good memory Yes No 
Good deeds and helpfulness. Yes No 
(Helpful nature)
Boasting, envy Yes No 
(Jealous of other's success)
Exploiting others at their weak points. Yes No   
Unclean / bad food habits Yes No 
Arouses fear in others Yes No 
Indolence Yes No 
(Lazy & Unwillingness to work)
Passion Yes No 
Grief Yes No 
Non comprehension Yes No 
Vanity Yes No  
(Excessive pride in ones appearance, qualities, achievements)
Absence of truthfulness Yes No 
Non forgiving nature Yes No 
Excessive self confidence Yes No  
Anger Yes No 
Harsh nature Yes No  
Unsteadiness Yes No  
( Restless & inability to remain seated for a period of time)
Lack of intelligence Yes No   
Despondency Yes No  
(Feeling helpless downhearted, gloomy)
Stupidity Yes No  
Ignorance Yes No  
Wickedness Yes No  
(Tendency to perform evil acts)
Fatigue Yes No  
(Feeling of tiredness / dullness)
Sleepiness Yes No   
( Feel sleepy during the day)
Sorrow Yes No  
Fear Yes No  
( Easily frightened)

Appetite, Diet & Habits
.          Are you a voracious eater? Does the food get digested easily?

•        Do you have problems like heaviness, feeling weak and lethargy immediately after eating?

• Do you have any pain in the abdomen, specially after eating or on empty stomach? If yes, specify the area of pain.

• Do you have wind or gas?

• Do you over-eat?

• What kind of foods bother you ? What kind of trouble do you have when you take these foods?

• Do you often have acidity , burping with or without burning sensation in the stomach and chest?

• Any other information, that you would like to share?


It would be helpfull  if you could describe your diet. You can use the following guidelines, if you are not able to explain the diet.
Kinds of food usually taken:



• Are you a vegetarian? If not, how often do you eat meat, seafood or other kinds of non-vegetarian foods.

• Do you take snacks / foods in between your main meals? If yes, what and how often?

• Quantity of tea, coffee, alcohol, or any other kind of drinks taken in a day?

• How often do you eat fast foods, fried foods, frozen foods and foods that have been in the microwave?

• How much water do you usually drink in a day and when(before / after meal etc)?

• Quantity of milk products and sweets and their  types (eg:cheese,chocolate etc.,

• Addiction to any unhealthy habits?