Ayurveda Client Intake
This is a method of gathering data to formulate a personalized Ayurveda and Yoga lifestyle plan. Ayurveda is a way to support your health and wellness. It is intended to be used in combination with regular care under the direction of your regular physicians and/or medical professionals. Please complete it 48 hours prior to our first session.
Email address *
What is your name? *
Your answer
What is your address? *
Your answer
What is your phone number? *
Your answer
Please list all preferred e-mail addresses
Your answer
What is today's date? *
MM
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DD
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YYYY
Please list your preferred methods of contact in in order of top to least (text, email, phone) *
Your answer
What is your age? *
Your answer
What is your gender?
Comment space for previous question if needed.
Your answer
What is your height?
Your answer
What is your weight?
Your answer
What is your date of birth?
MM
/
DD
/
YYYY
What is your time of birth?
Time
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Where were you born?
Your answer
What is your marital status
What is your occupation?
Your answer
What health and wellness goals are your top priority?
Your answer
Please list the 3 main health problems you would like to be free of in order of importance. *
Your answer
How and when did these conditions begin?
Your answer
Do they impact your daily activities including sleep, and if so how?
Your answer
What health professionals have you seen about them?
Your answer
Do you frequently experience any of the following states of mind? Check all that apply.
Describe your movement, yoga, meditation or breathing practices (including frequency).
Your answer
Describe your diet for the last 3 days (including times of day, location & emotions).
Your answer
Describe your fluid intake for the last 3 days (include temperature, quantity and type).
Your answer
To explore your digestion, over the last 3-6 months, have you experienced any of the following
What has your sleep schedule been like for the last month? (include average times to sleep/wake)
Your answer
What if any types of dreams have you been experiencing?
Your answer
Describe any routines that help support your sleep.
Your answer
What does self care mean to you and how often do you set aside time for it?
Your answer
Describe your emotional support system.
Your answer
What other information would be helpful for me to know?
Your answer
What other information would be helpful for me to know?
Your answer
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