Nicola Turner Ayurveda Intake Form
Please fill out this comprehensive intake form to help Nicola Turner Ayurveda understand your health background, lifestyle, and goals for Ayurvedic practice.
Sign in to Google to save your progress. Learn more
Email *
Name:
Address:
Phone:
Email Address:
How did you come to me?
Birthdate:
MM
/
DD
/
YYYY
Number of Children:
Age:
Marital Status:
Clear selection
Height:
Occupation:
For how long have you had this occupation?
On a scale of 1-10, with 10 being high and 1 being low, how stressed do you feel each day?
Main purpose of visit:
Have you had unintentional weight loss or gain of 10 pounds or more in the last 3 months?
Clear selection
Are you taking any medications? Please list the name, use, and duration.
Please list any major hospitalizations, injuries, surgeries, illnesses, and/or accidents with procedure, year, and outcome.
Please share some of your family history and relevant ailments (e.g., type of cancer, diabetes, headaches, heart disease, other). Include relation and details.
Please list current complaints in order of severity with duration.
Please mark with an 'X' all symptoms you are experiencing:
Do you wear any of the following?
Would you like to (select all that apply):
Are you taking any supplements? (Select all that apply and specify where applicable)
Please specify other supplements or details for above:
Habit: Smoking Cigarettes / Cigars (Nicotine) - Serving Amount Consumed Per Day:
Habit: Smoking Marijuana - Serving Amount Consumed Per Day:
Habit: Drinking Liquor - Serving Amount Consumed Per Day:
Habit: Drinking Wine - Serving Amount Consumed Per Day:
Habit: Drinking Beer - Serving Amount Consumed Per Day:
Habit: Drinking Coffee (with Caffeine) - Serving Amount Consumed Per Day:
Habit: Drinking Tea (with Caffeine) - Serving Amount Consumed Per Day:
Habit: Drinking Soda - Serving Amount Consumed Per Day:
Habit: Other (please specify) - Serving Amount Consumed Per Day:
Exercise or Activity: Walking Duration (Minutes Per Week):
Exercise or Activity: Hiking Duration (Minutes Per Week):
Exercise or Activity: Running Duration (Minutes Per Week):
Exercise or Activity: Swimming Duration (Minutes Per Week):
Exercise or Activity: Dancing/Pilates Duration (Minutes Per Week):
Exercise or Activity: Other Cardio Duration (Minutes Per Week):
Exercise or Activity: Weight Lifting Duration (Minutes Per Week):
Exercise or Activity: Yoga Duration (Minutes Per Week):
Exercise or Activity: Flexibility / Stretching Duration (Minutes Per Week):
Exercise or Activity: Other Sports, Fitness, and Training Duration (Minutes Per Week):
Mark with an 'X' the time(s) of day you feel most energized and/or least symptoms:
Mark with an 'X' the time(s) of day you feel least energized and/or symptoms are aggravated:
Please share some brief information about your sleeping behavior (bedtime, falling asleep, dreams, night waking, waking time, feeling upon waking).
Foods you eat (favorite foods, meat and kind/frequency, dairy and kind/frequency).
Mark with an 'X' any special food allergies and/or restrictions:
Meal schedule: Please describe times, foods eaten or meals skipped for Breakfast, Lunch, Dinner, Snacks.
Breakfast
Lunch
Dinner
Snacks
Evacuation or elimination of bowel movements: Time of day, frequency, consistency, floats/sinks, color, odor, mucus, burning/straining, hemorrhoids, gas.
Evacuation or elimination of urine: Frequency, color, odor, relief at night, UTI/bacterial/yeast history.
For females only: First day of last period:
MM
/
DD
/
YYYY
Duration of period (# of days):
Describe any irregularities in your menstrual cycle:
How many pregnancies?
How many kids?
Any delivery difficulties?
How are your relationships with Family?
How are your relationships with Friends?
How are your relationships with Partner?
How are your relationships with Colleagues?
Discovering your passions: What are your passions?
What are your hobbies? How often do you live them? Have you lost any?
Are you a spiritual/religious person?
Clear selection
Do you have a spiritual practice? Please describe.
Would you like to have a spiritual practice?
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms