Chronoprakriti Assessment Form
Personal Information
Email:
*
Mobile Number:
First Name:
Last Name:
Address:
Town/Village:
City:
State:
Pin Code:
Country:
Gender:
*
Select
Male
Female
Transgender
Prefer Not to say
Occupation:
Date of Birth:
Time of Birth:
Place of Birth:
Place of Childhood:
Ayam / Height (in cm):
*
Vistar / Breadth (in cm):
Weight (in kg):
*
Weight Loss/Gain (Y/N):
Select
Yes
No
Blood Group:
Select
O+
O-
A+
A-
B+
B-
AB+
AB-
Your existing medical condition (max 300 words):
Lifestyle diseases, if any please describe (max 300 words):
Family history of specific disease (max 300 words):
Do you require / consume any stimulants (max 300 words):
Consumption of sleeping pills (Y/N):
Any regular medicines going on for last one month?
Apart from this, would you like to add anything about yourself?
Section 1
1. At what time do you wake up on work days?
*
Before 4 am
Between 4 am to 6 am
Between 6 am to 8 am
Between 8 am to 10 am
Between 10 am to 12 pm
After 12 pm
2. At what time do you wake up on free days?
*
Before 4 am
Between 4 am to 6 am
Between 6 am to 8 am
Between 8 am to 10 am
Between 10 am to 12 pm
After 12 pm
3. At what time do you sleep on work days?
*
Before 9 pm
Between 9 pm to 10 pm
Between 10 pm to 11 pm
Between 11 pm to 12 am
Between 12 am to 1 am
After 1 am
4. At what time do you sleep on free days?
*
Before 9 pm
Between 9 pm to 10 pm
Between 10 pm to 11 pm
Between 11 pm to 12 am
Between 12 am to 1 am
After 1 am
5. Ease of waking up assuming adequate environmental / physical conditions
*
Very easy
Easy
Not so easy
Not at all easy
6. Dependency on alarm clocks
*
Not at all dependent
Slightly dependent
Less dependent
Highly dependent
7. Time spent reading book / using phone / laptop / watching TV etc before going to bed
*
Less than 30 min
30 min - 1 hr
1 hr - 2 hrs
Beyond 2 hrs
8. Duration taken to fall asleep
*
Less than 15 min
15 min – 30 min
30 min – 1 hr
Beyond 1 hr
9. How alert do you feel in the first half an hour after waking up?
*
Most alert
Alert
Slightly alert
Least alert
10. How long does it take to attain complete alertness?
*
Less than 15 min
15 min – 30 min
30 min – 45 min
45 min – 60 min
More than 1 hr
11. How tired do you feel after first thirty minutes of waking up?
*
Least tired
Slightly tired
Tired
Most tired
12. There is every possibility of falling asleep during following situations in day time
*
Not applicable
Sitting & Reading
Between 8 am to 10 am
Between 10 am to 12 pm
After 12 pm
13. For some reason you have to go to bed several hours later than usual, but there is no need to wake up at any particular time next morning. You will prefer
*
Wake up at the usual time and not go back to sleep
Wake up at the usual time and doze
Wake up at the usual time and go back to sleep
Wake up later than usual
14. One night you have to remain awake between 4 am to 6 am. You have no commitments next day, which suits you best?
*
Sleep before 4 am and remain awake after 6 am
Sleep before 4 am and nap after 6 am
Nap before 4 am and sleep after 6 am
Not to go to bed till 6 am
15. You are required to be at your peak for a test which is going to be a mentally exhaustive test and lasting for two hours. Which two hours you will prefer, if you were free to plan your day?
*
Before 8 am
Between 8 am to 10 am
Between 11 am to 1 pm
Between 3 pm to 5 pm
Between 7 pm to 9 pm
After 9 pm
16. If you were to work for 5 hours, what time slot would you prefer the most?
*
Before 7 am
Between 7 am to 12 pm
Between 10 am to 3 pm
Between 1 pm to 6 pm
Between 4 pm to 9 pm
After 6 pm
17. When are you most active during your working hours?
*
First quarter
Second quarter
Third quarter
Fourth quarter
18. You have to do hours of physical work, which hours would you prefer to do it between?
*
Before 8 am
Between 8 am to 10 am
Between 3 pm to 5 pm
Between 7 pm to 9 pm
After 9 pm
19. You have decided to engage in some physical exercises, a friend suggests that you do this between 10.00 pm to 11.00 pm in the night twice a week. How do you think, you would like to perform?
*
Very difficult
Difficult
Slightly difficult
Not at all difficult
20. How many hours of natural light are you exposed to on working days?
*
Beyond 4 hrs
Between 2 hrs to 4 hrs
Between 1 hr to 2 hrs
Less than 1 hr
21. How many hours of natural light are you exposed to on free days?
*
Beyond 4 hrs
Between 2 hrs to 4 hrs
Between 1 hr to 2 hrs
Less than 1 hr
22. How many hours of artificial lights are you exposed to on working days?
*
Less than 4 hrs
Between 4 hrs to 6 hrs
Between 6 hrs to 10 hrs
More than 10 hrs
23. How many hours of artificial light are you exposed to on holidays?
*
Less than 4 hrs
Between 4 hrs to 6 hrs
Between 6 hrs to 10 hrs
More than 10 hrs
24. Time of your dinner on work day
*
Between 7 pm to 8 pm
Between 8 pm to 9 pm
Between 9 pm to 10 pm
After 10 pm
25. Time of your dinner on free day
*
Between 7 pm to 8 pm
Between 8 pm to 9 pm
Between 9 pm to 10 pm
After 10 pm
Section 2
26. Do your veins and tendons (muscle endings) all over the body are clearly visible?
*
Yes
No
27. Do you make frequent movements of joints (jaws, knees etc)?
*
Yes
No
28. Is there any sound on normal movement especially in knees or ankles?
*
Yes
No
29. Do you have dry or rough eyes?
*
Yes
No
30. Do you have / had unevenly arranged teeth?
*
Yes
No
31. Are your nails dry and rough?
*
Yes
No
32. Is your skin colour dark?
*
Yes
No
33. Is your skin colour dusky?
*
Yes
No
34. Is the colour of your eyes hazy white?
*
Yes
No
35. Is texture of your hair (Scalp/Body hair/ Moustache) hard?
*
Yes
No
36. Is the colour of your hair (Scalp/Body hair/ Moustache) dusky?
*
Yes
No
37. Do you have crack skin on soles and/or palms?
*
Yes
No
38. Are your eyes small?
*
Yes
No
39. Are your nails small?
*
Yes
No
40. Do your eyes remain half open during sleep?
*
Yes
No
41. Is your body sensitive to excessive cold season?
*
Yes
No
42. Do you frequently get dreams of walking /flying in the sky / mountains / dried water bodies / trees etc.?
*
Yes
No
43. Do you walk fast?
*
Yes
No
44. Do you respond promptly to given task?
*
Yes
No
45. Is your voice harsh / cracked?
*
Yes
No
46. Do you have frequent sleep disturbance?
*
Yes
No
47. Do you have tendency towards constipation / hard stool?
*
Yes
No
48. Do you often forget some important jobs / things like filling tuitions fees, electricity bills, important dates and later remember it?
*
Yes
No
49. Do you have slightly anxious nature?
*
Yes
No
50. Are you talkative?
*
Yes
No
Section 3
51. Do you have pink tinge on nails and nail beds?
*
Yes
No
52. Is your skin fair with wheatish tinge?
*
Yes
No
53. Is the colour of your eyes reddish?
*
Yes
No
54. Is texture of your hair (Scalp/Body hair/ Moustache) soft silky?
*
Yes
No
55. Is the colour of your hair (Scalp/Body hair/ Moustache) brownish?
*
Yes
No
56. Do you have moles, pimples, and freckles on your skin?
*
Yes
No
57. Is your body sensitive to excessive heat/summer season?
*
Yes
No
58. Is your body sensitive to excessive hot and spicy food items?
*
Yes
No
59. Do you have frequent reddening of your eyes on exposure to heat and sunlight?
*
Yes
No
60. Do you have a tendency of early hair loss / baldness?
*
Yes
No
61. Do you have a tendency of greying of hair?
*
Yes
No
62. Do you frequently get dreams of fire / lightning / gold / red flowers / falling of meteors etc.?
*
Yes
No
63. Do you respond promptly to a given task?
*
Yes
No
64. Is your voice feeble?
*
Yes
No
65. Are you alert in sleep?
*
Yes
No
66. Do you have a tendency towards slightly unformed/semi-solid stool?
*
Yes
No
67. Do you have frequent feelings of hunger / frequent intake of food?
*
Yes
No
68. Do you have intense body odour from armpits / mouth / head?
*
Yes
No
69. Do you prefer cold over hot beverages?
*
Yes
No
70. Is your touch warmer?
*
Yes
No
71. Generally do you become restless if you don’t get food when you are hungry?
*
Yes
No
72. Generally do you become restless if you don’t get water when you are thirsty?
*
Yes
No
73. Do you have tendency towards profuse sweating?
*
Yes
No
74. Do you lose your temper and become restless in unfavourable conditions?
*
Yes
No
75. Are you a dominant speaker?
*
Yes
No
Section 4
76. Do your veins and tendons (muscle endings) all over the body are clearly visible?
*
Yes
No
77. Do you make frequent movements of joints (jaws, knees etc)?
*
Yes
No
78. Is there any sound on normal movement especially in knees or ankles?
*
Yes
No
79. Do you have glossy (Snigdha) eyes?
*
Yes
No
80. Do you have / had evenly arranged teeth?
*
Yes
No
81. Do you have glossy (Snigdha) nails?
*
Yes
No
82. Is your skin colour fair?
*
Yes
No
83. Is your skin glossy (Snigdha)?
*
Yes
No
84. Is the colour of your eyes milky white?
*
Yes
No
85. Is texture of your hair (Scalp/Body hair/ Moustache) oily?
*
Yes
No
86. Is the colour of your hair (Scalp/Body hair/ Moustache) black?
*
Yes
No
87. Do you have smooth & soft skin on soles and on palms?
*
Yes
No
88. Are your eyes big?
*
Yes
No
89. Are your nails big?
*
Yes
No
90. Is your forehead broader than width of four horizontal fingers?
*
Yes
No
91. You do not face a problem of hair fall.
*
Yes
No
92. Do you frequently get dreams of water bodies / lotus / water birds swan, duck etc.?
*
Yes
No
93. Do you walk slowly?
*
Yes
No
94. Do you need some time to respond to a given task?
*
Yes
No
95. Is your voice deep?
*
Yes
No
96. Is your sleep deep?
*
Yes
No
97. Do you generally get well-formed soft stools?
*
Yes
No
98. Are you able to tolerate your hunger?
*
Yes
No
99. Do you need less water?
*
Yes
No
100. Do you have a tendency of less sweating?
*
Yes
No
101. Do you generally forget some important jobs / things like filling tuition's fees, electricity bills, important dates and later remember it?
*
Yes
No
102. Do you remain calm and respond peacefully to unfavourable conditions?
*
Yes
No
103. Do you prefer not to talk much?
*
Yes
No
Submit