From The 3-Season Diet by Dr. John Douillard DC

From The 3-Season Diet by Dr. John Douillard DC

Patient's Name:

Date:

Instructions (Please send completed paperwork to us 5 days prior to your scheduled appointment)

Complete on a Computer

Complete Handwritten

1. Save this form to your computer.

1. Print out this form.

2. For each category, check the boxes next to the

2. For each category, check the boxes next to the

options that best describes how you or your

options that best describes how you or your

child most recently are (if your child is the

child most recently are (if your child is the

patient) ? within the past few weeks.

patient) ? within the past few weeks.

3. Read across the page from left to right. For

3. Read across the page from left to right. For

example, for the category `Mental activity' ?

example, for the category `Mental activity' ?

check `quick mind, restless'.

check `quick mind, restless'.

4. If you feel you/your child can equally relate to

4. If you feel you/your child can equally relate to

more than one of the descriptions, check all

more than one of the descriptions, check all

that apply.

that apply.

5. After finishing a profile, the form will

5. After finishing a profile, for each column, tally

automatically tally up your choices.

up how many descriptions you checked. This

6. After finishing the profiles, the form will have

automatically populated the profile totals for

number goes into the Subtotal row at the bottom of each profile.

the Totals Chart on page 4.

6. After finishing the profiles, please record your

7. Note the column you have the most points in,

profile totals for the Totals Chart on page 4.

and then find the corresponding Body Type.

7. Note the column you have the most points in,

You can read about your Body Type on the last

and then find the corresponding Body Type.

page of this questionnaire.

You can read about your Body Type on the last

8. Save this completed form to your computer

page of this questionnaire.

and upload it securely at the webpage:

8. Fax or scan/upload this form back to



(303) 530-4409 or upload it securely here:

.

MENTAL PROFILE

Category Mental activity

Memory Thoughts Concentration

Ability to learn

Dreams

Sleep Speech

Voice

WINTER / VATA Quick mind, restless

Short-term best Constantly changing Short-term focus best

Quick grasp of learning

Fearful, flying, running, jumping Interrupted, light Fast, sometimes missing words High pitch

SUMMER / PITTA Sharp intellect, aggressive Good general memory Fairly steady Better than average mental concentration Medium to moderate grasp Angry, fiery, violent, adventurous Sound, medium Fast, sharp, clear-cut

Medium pitch

SPRING / KAPHA Calm, steady, stable

Long-term best Steady, stable, fixed Good ability for longterm focus Slow to learn new things

Include water, clouds, relationships, romance Sound, heavy, long Slow, clear, sweet

Low pitch

Mental subtotal:

0

0

0

6662 Gunpark Drive, Suite 102 Boulder, CO 80301

? 2008-2014

Phone: 303.516.4848, Fax: 303.530.4409 admin@,

Category Eating speed Hunger level

Food and drink Achieving goals Giving/donations

Relationships Sex drive Works best Weather preference Reaction to stress Financial

Friendships

Behavioral subtotal:

BEHAVIORAL PROFILE

WINTER / VATA Quick Irregular

Prefers warm Easily distracted Gives small amounts

Many casual Variable or low While supervised Aversion to cold Excites quickly Doesn't save, spends quickly Tends toward shortterm friendships, makes friends quickly

SUMMER / PITTA Medium Sharp, needs food when hungry Prefers cold Focused and driven Gives nothing, or large amounts infrequently Intense Moderate Alone Aversion to heat Medium Saves, but big spender

Tends to be a loner, friends related to occupation

0

0

SPRING / KAPHA Slow Can easily miss meals

Prefers dry and warm Slow and steady Gives regularly and generously Long and deep Strong In groups Aversion to damp, cool Slow to get excited Saves regularly, accumulates wealth Tends to form longlasting friendships

0

Category Moods Reacts to stress with More sensitive to When threatened, tends to Relations with spouse/partner Expresses affection When feeling hurt Emotional trauma causes Confidence level

Emotional subtotal:

EMOTIONAL PROFILE

WINTER / VATA Change quickly Fear Own feelings Run

SUMMER / PITTA Change slowly Anger Not sensitive Fight

Clingy

Jealous

With words Cries Anxiety

With gifts Argues Denial

Timid

Outwardly selfconfident

SPRING / KAPHA Steady, unchanging Indifference Others' feelings Make peace

Secure

With touch Withdraws Depression

Inner confidence

6662 Gunpark Drive, Suite 102 Boulder, CO 80301

? 2008-2014

Phone: 303.516.4848, Fax: 303.530.4409 info@,

Amount of hair Hair type Hair color Skin Skin temperature Complexion Eyes Whites of eyes Size of teeth Weight Elimination

Resting pulse Men Women

Veins and tendons

Physical subtotal:

PHYSICAL PROFILE

WINTER / VATA Average Dry Light brown, blonde Dry, rough, or both Cold hands/feet Darker Small Blue/brown Very large or very small Thin, hard to gain Dry, hard, thin, easily constipated

SUMMER / PITTA Thinning Normal Red, auburn Soft, normal to oily Warm Pink-red Medium Yellow or red Small-medium Medium Many during day, soft to normal

SPRING / KAPHA Thick Oily Dark brown, black Oily, moist, cool Cool Pale-white Large Glossy white Medium-large Heavy, gains easily Heavy, slow, thick, regular

70-90 80-100 Very prominent

60-70 70-80 Fairly prominent

50-60 60-70 Well covered

Exercise tolerance Endurance Strength Speed Competition

Walking speed Muscle tone

Runs like Body size

Reaction time Fitness subtotal:

FITNESS PROFILE

WINTER / VATA Low Fair Fair Very good Doesn't like competitive pressure Fast Lean, low body fat

Deer Small frame, lean or long Quick

SUMMER / PITTA Medium Good Better than average Good Driven competitor

Average Medium, with good definition Tiger Medium frame

Average

SPRING / KAPHA High Excellent Excellent Not so fast Deals easily with competitive pressure Slow and steady Brawny/bulky, with higher fat percentage Bear Large frame, fleshy

Slow

6662 Gunpark Drive, Suite 102 Boulder, CO 80301

? 2008-2014

Phone: 303.516.4848, Fax: 303.530.4409 info@,

Patient's Name:

Profile

Mental Behavioral Emotional Physical Fitness TOTAL:

Date:

TOTALS Your Primary Body Type is the column you scored highest in.

WINTER / VATA

SUMMER / PITTA

SPRING / KAPHA

0

0

0

0

0

0

0

0

0

0

0

0

0

6662 Gunpark Drive, Suite 102 Boulder, CO 80301

? 2008-2014

Phone: 303.516.4848, Fax: 303.530.4409 info@,

FOR YOUR USE AND REFERENCE

Vata- Winter

Pitta- Summer

Governs

Nervous System

Digestion

Season

Winter

Summer

Time of Day

2:00-6:00 a.m.: 2:00-6:00 p.m.:

Wake Up 10:00 am - 2:00pm: Digest

Think

10:00pm - 2:00am: Cleanse

Taste/Qualities Pungent, Bitter, Astringent/ Aggravating Light, Cold, Dry

Pungent, Sour, Salty/ Hot, Light, Dry

Kapha- Spring

Structure

Spring

6:00-10:00 a.m. : Exercise 6:00-10:00 p.m.: Sleep

Sweet, Sour, Salty/ Heavy, Oily, Cold

Taste/Qualities Sweet, Sour, Salty/

Balancing

Heavy, Oily, Hot

Sweet, Bitter, Astringent/ Cold, Heavy, Oily

Pungent, Bitter, Astringent/ Light, Dry, Hot

Beneficial Oils Sesame, Almond, Apricot

Sesame, Coconut, Sunflower Sesame, Olive

WINTER- VATA: Air Vata is the most important of the three doshas. If left unbalanced it causes Pitta and Kapha to become imbalanced. Vata is the main driver or mover of the body, providing these functions:

All elimination's: fetus, semen, feces, urine, and sweat. Assists with metabolisms in the body (Agni), transformation of tissues. Controls movement in body (mental and physical) such as respiration, heartbeat, motivation,

contraction of muscles, and natural urges. Relays all sensory input to the brain, motor functions. Governs nervous system.

SUMMER- PITTA: Fire Wherever there is transformation, there is Pitta. Pitta provides the following functions:

Metabolism, from digestion of food to transformation of all other material. Thermogenesis ? maintains the proper body temperature. Vision. Comprehension of information into knowledge / reasoning and judgment. Complexion ? gives color and softness to skin.

SPRING- KAPHA: Earth, Water Kapha is the heaviest of the three doshas. It provides the structures and the lubrication that the body needs. Kapha provides the following functions:

Strength and energy. Moistness & Lubrication. Stability to add the necessary grounding aspect to both mind and body. Mass and structure to provide fullness to bodily tissues. Fertility & Virility.

6662 Gunpark Drive, Suite 102 Boulder, CO 80301

? 2008-2014

Phone: 303.516.4848, Fax: 303.530.4409 info@,

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