Ayurveda Intake Form
Please fill this out at least 24 hours before your consultation. Should take anywhere between 15-30 minutes
Email address *
Date: *
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YYYY
Full Name: *
Your answer
Sex: *
Marital Status: *
Age: *
Your answer
Height: *
Your answer
Weight: *
Your answer
Occupation: *
Your answer
Phone: *
Your answer
City & State: *
Your answer
Please describe your present health concerns and their duration: *
Your answer
Are you currently under the care of a family physician or any other health professional? If yes, please explain
Your answer
Are you currently taking any medications and/or receiving any medical treatment for your health condition? If so, please list all medications/treatments and their dosage.
Your answer
Are you allergic to any substances? Please specify: food, pollen, dust, etc., and any other allergic reactions?
Your answer
Do you have any past medical history? If yes, please specify the age of occurrence, duration, and its treatment.
Your answer
HEALTH AS A CHILD
HOW WOULD YOU RATE YOUR USUAL ENERGY LEVEL?
NATURAL URGES
Do you delay or suppress any of the following?
SLEEPING
What time do you go to sleep? What time do you wake up?
Your answer
Do you sleep during the day?
How do you generally feel when you wake up in the morning?
How is your sleep?
EMOTIONS
What is your current state of mind and emotions?
Do you often experience any of the following?
How are your family relationships?
How is your social life?
How is your mental status?
How is your career?
How purposeful is your life?
Rate your spiritual life:
DAILY ROUTINE
How regular is your daily routine (for example, do you go to bed early, eat meals at the same time each day, exercise regularly, etc.)?
Do you practice any type of meditation? Please explain
Your answer
Do you practice any yoga techniques? Please explain
Your answer
Do you travel a lot?
How often do you smoke cigarettes?
How often do you drink alcohol?
How often do you drink caffeinated beverages?
Which type of weather makes you feel most uncomfortable?
PHYSICAL BODY
What is your body build?
Are you overweight?
If so, by how much?
Your answer
How often do you exercise?
How long of exercise and what type?
Your answer
Is your exercise (choose one)
FOOD PRACTICES
Daily
4-7 x weekly
2-3 x Weekly
1-2 x monthly
Never
Grains / Cereals
Fruits
Vegetables
Meat / Poultry / Seafood
Dairy
Eggs
Desert
Sugar / Honey
Juices
Please explain what you typically eat for breakfast, lunch, dinner and snacks:
Your answer
Do you eat between meals?
Do you eat your meals at the same time daily?
Which is your main meal?
My eating habits include:
Describe your diet:
DIGESTION
Are there any particular foods that create discomfort when you eat them?
Do you experience any of the following?
Bowel Movements
Bowel Nature
Soft
Medium
Hard
.
Bowel Movement Associated with:
Rate your digestion:
URINATION
Do you have any of the following urinary problems?
How much water do you drink per day?
SEX
Do you experience pain during intercourse?
Do you have any sexual difficulties?
FOR WOMEN
Age menses began:
Your answer
Which of the following describes your menstruation?
How many days does your menstrual period last?
How is your menstrual flow?
Associated Symptoms (before or during menstruation):
Are you pregnant now?
Do you take contraceptive pills or use other forms of birth control?
Number of previous pregnancies:
Your answer
How many children do you have?
Your answer
Any other comments and/or questions?
Your answer
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