Healthy Weight Intake Form

Vata Balance

Please select how frequently you experience each symptom. If you do not experience it, please skip to the next question.

Light-headed

Often
Very Often
Continuously

Dizziness

Often
Very Often
Continuously

Low Blood Sugar

Often
Very Often
Continuously

Low Blood Pressure

Often
Very Often
Continuously

Type 1 Diabetes

Often
Very Often
Continuously

Anxiety or worry

Often
Very Often
Continuously

Insomnia

Often
Very Often
Continuously

Constipation

Often
Very Often
Continuously

Gas

Often
Very Often
Continuously

Bloating

Often
Very Often
Continuously

Stomach Cramping

Often
Very Often
Continuously

Menstrual Irregularity

Often
Very Often
Continuously

Delayed Menstruation

Often
Very Often
Continuously

Painful Menstrual Cycle

Often
Very Often
Continuously

Low Energy (due to fatigue or sleep problems)

Often
Very Often
Continuously

Sensitive Stomach

Often
Very Often
Continuously

Food Allergies

Often
Very Often
Continuously

Panic Attacks

Often
Very Often
Continuously

Lower Back Pain/ Sciatica

Often
Very Often
Continuously

Pitta Balance

Please select how often you experience each symptom. If you do not experience it, skip to the next question.

High Blood Pressure

Often
Very Often
Continuously

Skin Break outs

Often
Very Often
Continuously

Sensitive Skin

Often
Very Often
Continuously

Acid Reflux

Often
Very Often
Continuously

Inflammation in the body/ skin

Often
Very Often
Continuously

Gallbladder pain/ inflammation

Often
Very Often
Continuously

Excessive Sweating

Often
Very Often
Continuously

Urinary Tract Infections

Often
Very Often
Continuously

Burning Urination

Often
Very Often
Continuously

Night Sweating

Often
Very Often
Continuously

Loose Stools

Often
Very Often
Continuously

Diarrhea

Often
Very Often
Continuously

Burning Stools

Often
Very Often
Continuously

Heavy Menstruation

Often
Very Often
Continuously

Fever

Often
Very Often
Continuously

High Thirst

Often
Very Often
Continuously

Kapha Balance

Select the frequency you experience each symptom. If you do not experience it, skip to the next question.

High Blood Sugar

Often
Very Often
Continuously

Diabetes (Type II, Adult Onset)

Often
Very Often
Continuously

Lethargy

Often
Very Often
Continuously

Very Heavy Sleep

Often
Very Often
Continuously

Sluggish Feeling

Often
Very Often
Continuously

Sluggish/ slow digestion

Often
Very Often
Continuously

Frequently tired (not from lack of sleep)

Often
Very Often
Continuously

Depression

Often
Very Often
Continuously

Mental Foginess

Often
Very Often
Continuously

Sinus Infections/ colds

Often
Very Often
Continuously

Yeast Infections

Often
Very Often
Continuously

Step 1 of 4 - Personal Information

Vata Balance

Pitta Balance

Kapha Balance

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