Ayurveda Treatment Intake Form
Thank you for taking the time to fill out this form. This will allow me to gain a better understanding of you, your goals for our work together, and how I can best support you in your journey.
Client Name: *
Your answer
Phone Number: *
Your answer
Date of Birth: *
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Address: *
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Email: *
Your answer
What are your primary health concerns at this time? *
Your answer
What do you hope to accomplish with your Ayurvedic experience? *
Your answer
Briefly describe your current diet, including typical meals for breakfast, lunch, and dinner. *
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Do you have any known food allergies or sensitivities? If so, please list them here.
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How often do you consume alcohol? *
How would you describe your caffeine consumption? *
Do you vape or use tobacco? *
How often do you currently exercise? *
What is your preferred type of exercise? *
Your answer
Do you have previous experience with meditation? *
If yes, please briefly describe your experience with meditation - if you have found it successful, the types of meditation you have practiced, frequency, etc.
Your answer
Do you have previous experience with Ayurvedic treatment? *
If you have experienced Ayurvedic treatment in the past, please briefly describe your experience, including the types of treatment, outcomes, and frequency of treatments.
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Are you aware of your Doshas? If so, please list them here. If not, please visit my website at ayurvedicway.com and take the quiz, found under the Doshas tab. Afterwards, please email your results to nurturingyou@gmail.com.
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