Personalized Ayurveda Diet Intake

Welcome to Your Personalized Ayurveda Diet Intake 🌿

Thank you for taking this important step toward nourishing your body, mind, and spirit. Please complete the form below with as much care and honesty as you wish. Your responses will help me create a plan that is truly aligned with your unique needs.

I’m honored to walk this journey with you. ✨With gratitude, Jennifer

Basic Information

First name

Email

Phone

Location (City/State or Country)

Birthday

Month

Day

Year

Dosha & Imbalance Discovery

How would you describe your digestion most days? (check all that apply)

Strong appetite, eat anything easily

Variable appetite, sometimes ravenous, sometimes none

Slow appetite, often feel heavy after eating

Bloating, gas, or indigestion

Heartburn or acidity

Constipation (dry, hard stool)

Loose stool or diarrhea

Alternating constipation/diarrhea

Other

How would you describe your energy levels throughout the day? (check all that apply)

How would you describe your mental/emotional state lately? (check all that apply)

Food Preferences, Allergies, and Restrictions

Please list any known food allergies or intolerances:

Are you currently following any particular diet or eating style? (Examples: vegetarian, vegan, paleo, low carb, intermittent fasting, etc.)

How would you describe your typical cooking habits?

I love cooking and have time for it

I like cooking but prefer quick and simple meals.

I don't like cooking and prefer very easy options

Other

Would you like recipes included in your plan or just meal ideas?

Yes, I would like simple recipes

No, meal ideas are enough

Special Considerations

How would you describe your current stress level?

Low

Moderate

High

Very High

Anything else you would like me to know about your lifestyle, health goals, or daily routines?

Consent and Acknowledgment

Thank you for trusting me to support your journey through Ayurveda and nourishment. This personalized diet plan is intended for educational and informational purposes only, based on the wisdom of Ayurveda and the information you have shared with me. It is not a substitute for medical advice, diagnosis, or treatment. I am not a medical doctor and do not diagnose, treat, or cure disease. Please consult your healthcare provider before making major changes to your diet or lifestyle, especially if you have a medical condition or are taking medications. By submitting this form, you acknowledge and agree to these terms.

I agree to the terms above.