Shakti Botanicals — Ayurvedic Clinical Assessment

This assessment maps your Prakriti — the unique constitutional intelligence you were born with — and your Vikriti, the current expression of your nature. There is no right or wrong here. Simply observe yourself with honesty and stillness, as Ayurveda has guided us to do for over five thousand years.

0 — Never | 1 — Mild | 2 — Moderate | 3 — Strongly characteristic

Patient Name

Date of Birth

Assessment Date

Structural Constitution

Clinical Question	Score 0 Never 1 Mild 2 Moderate 3 Strong
Thin bones and visible joints	0 1 2 3
Moderate muscular definition	0 1 2 3
Dense bones and broad frame	0 1 2 3
Difficulty maintaining weight	0 1 2 3
Heat generated during exertion	0 1 2 3
Excellent physical endurance	0 1 2 3

Skin & Connective Tissue

Clinical Question	Score 0 Never 1 Mild 2 Moderate 3 Strong
Dryness and rough texture	0 1 2 3
Inflammatory or sensitive skin	0 1 2 3
Cold, oily or thick skin	0 1 2 3
Veins highly visible	0 1 2 3
Redness or flushing tendency	0 1 2 3
Water retention or edema	0 1 2 3

Hair & Nails

Clinical Question	Score 0 Never 1 Mild 2 Moderate 3 Strong
Dry brittle hair	0 1 2 3
Premature greying	0 1 2 3
Thick heavy hair	0 1 2 3
Weak or splitting nails	0 1 2 3
Soft warm scalp	0 1 2 3
Oily scalp or dandruff accumulation	0 1 2 3

Digestive Function

Clinical Question	Score 0 Never 1 Mild 2 Moderate 3 Strong
Irregular hunger patterns	0 1 2 3
Strong appetite with irritability if fasting	0 1 2 3
Slow digestion and post-meal heaviness	0 1 2 3
Gas and abdominal distension	0 1 2 3
Acidity or burning sensation	0 1 2 3
Mucus accumulation after meals	0 1 2 3
Constipation tendency	0 1 2 3
Loose stools tendency	0 1 2 3
Sluggish elimination	0 1 2 3

Neurological & Sensory

Clinical Question	Score 0 Never 1 Mild 2 Moderate 3 Strong
Sensitivity to noise	0 1 2 3
Sensitivity to bright light	0 1 2 3
Slow sensory responsiveness	0 1 2 3
Restless movements or fidgeting	0 1 2 3
Intense focused gaze	0 1 2 3
Slow calm body language	0 1 2 3

Sleep Patterns

Clinical Question	Score 0 Never 1 Mild 2 Moderate 3 Strong
Light fragmented sleep	0 1 2 3
Dream intensity and vivid imagery	0 1 2 3
Heavy prolonged sleep	0 1 2 3
Waking between 2–4am	0 1 2 3
Waking overheated	0 1 2 3
Difficulty waking in the morning	0 1 2 3

Mental Function

Clinical Question	Score 0 Never 1 Mild 2 Moderate 3 Strong
Rapid thoughts and ideation	0 1 2 3
Analytical and strategic thinking	0 1 2 3
Slow but stable comprehension	0 1 2 3
Difficulty grounding mentally	0 1 2 3
Perfectionistic tendencies	0 1 2 3
Attachment to routine	0 1 2 3

Emotional Patterns

Clinical Question	Score 0 Never 1 Mild 2 Moderate 3 Strong
Fear and insecurity	0 1 2 3
Irritability and frustration	0 1 2 3
Attachment and emotional stagnation	0 1 2 3
Emotional instability	0 1 2 3
Critical inner dialogue	0 1 2 3
Resistance to change	0 1 2 3

Stress Response

Clinical Question	Score 0 Never 1 Mild 2 Moderate 3 Strong
Nervous exhaustion under stress	0 1 2 3
Anger and control under stress	0 1 2 3
Withdrawal and passivity under stress	0 1 2 3
Insomnia from stress	0 1 2 3
Inflammatory reactions during stress	0 1 2 3
Emotional eating under stress	0 1 2 3

Reproductive & Hormonal

Clinical Question	Score 0 Never 1 Mild 2 Moderate 3 Strong
Irregular cycles or hormonal fluctuation	0 1 2 3
Heat or inflammation during cycle	0 1 2 3
Water retention during cycle	0 1 2 3
Low reproductive vitality due to depletion	0 1 2 3
Strong libido and intensity	0 1 2 3
Stable fertility and sensuality	0 1 2 3

Environmental Response

Clinical Question	Score 0 Never 1 Mild 2 Moderate 3 Strong
Aversion to cold wind	0 1 2 3
Aversion to heat and sun	0 1 2 3
Aversion to humidity and dampness	0 1 2 3
Feels restored by warmth	0 1 2 3
Feels restored by coolness	0 1 2 3
Feels restored by stimulation and movement	0 1 2 3

Spiritual & Behavioural Tendencies

Clinical Question	Score 0 Never 1 Mild 2 Moderate 3 Strong
Highly imaginative and visionary	0 1 2 3
Driven toward achievement and leadership	0 1 2 3
Naturally compassionate and nurturing	0 1 2 3
Starts projects rapidly	0 1 2 3
Needs control and precision	0 1 2 3
Maintains long-term consistency	0 1 2 3

Clinical Dosha Summary

Vata

Pitta

Kapha

Primary dosha will appear as you complete the assessment

Clinical Observations

Recommendations

Practitioner

Name ___________________________________

Date

Assessment complete. Thank you.