Ayurveda Intake Form

Ayurveda is the medicine that is practiced in India. It is an ancient science filled with ancient wisdom. The main goal of Ayurveda is to bring yourself back into balance through diet, lifestyle and other health practices (including yoga), so that you can live a healthy life feeling your best. Everyone is unique, and Ayurveda addresses each person as an individual.

Achieving your health goals won’t happen overnight. It takes time to bring your body back into balance. I high recommend 3 follow up sessions after you initial consultation. Please ask me about packages if you are interested.

This Intake Form will help me evaluate what is currently going on with you, as well as understanding your path. Please answer honestly and with details so that I can best support you to achieve your health goals. Make sure you have adequate time to fill out the form and return it to me 48 hours prior to your appointment (if your appointment is scheduled less than 48 hours prior to your appointment, please fill this out immediately and get it back to me).

Everything shared in this form is confidential. Some questions might seem very personal. All the questions here are to help me get a clear picture of your current state to see where you are out of balance so we can work towards bringing you back to balance. Every question below is related to topics that I have been trained to discuss. (Please note that if you are being harmed, plan to harm someone else, or plan to harm yourself, I am required by law to break confidentiality to make sure you get the help you need.)

First Name

Last Name

Email Address

Mailing Address

Phone number

Birthday

Place of birth

What is your previous experience with Ayurveda?

What are your primary health goals or concerns you want to address in working together?

Overall Health Evaluation

Are you currently under the care of a medical doctor or other health care provider? Please describe why and what is the treatment.

Have you had any major illness or condition? Please describe.

Have you had any operations? If yes, please list them, including the year of the operation.

Do you have a history of taking antibiotics? Please describe.

Do you have any allergies?

Family Health History: Please describe any family illnesses and/or long-term emotional conditions. List family member and illness/condition.

Medications/Herbs/Supplements: Please write down anything you are currently taking and any medications you have taken in the past (including childhood). Please provide apporximates dates.

Do/did you smoke? When? How much?

Do you drink alcohol? How much?

Do you take recreational drugs?

Do you drink caffeine? (Tea or coffee) If so, how many times a day?

How is your general energy level? Is it stable through the day? Do you have an energy slump? If so, what time? How is your overall mood? Please describe.

Do you exercise regularly? What do you do? How often and for how long?

Please answer ALL of the following questions: (1)How is your sleep? (2)Do you have trouble falling asleep or do you wake up at night? (3)What time do you go to bed and if you wake up in the middle of the night what time(s) do you wake up? (4)How many hours do you sleep? (5)Do you nap? If so, for how long? (6)Do you feel rested in the morning? (7)What are your dreams like? Do you remember them?

Please answer ALL of the following questions: (1)Do you have regular bowel movements each day? (2)Do you suffer from constipations or diarrhea? (3)Do your bowel movements float or sink? (4)What is their general color? (5)Do you they have undigested food particles? (6)Is there any burning? (7)Do your bowel movements ever feel incomplete?

Please answer ALL of the following questions: (1)How is your urination? (2)What is the frequency and color? (3)Is there an odor? (4)Do you wake up to pee in the night? If so, how often and what times?

For women only – Please answer ALL of the following questions: If you have gone through menopause, please say so and answer for how it used to be. (1)Do you have regular menstruation? (2)What is the frequency? (3)How long does it last? (4)Is there any pain or difficulty? (5)Do you have clots? (6)What is the color?

For women only: What is your form of birth control? Have you been pregnant before? How many pregnancies?

Emotional Well-Being

Are you seeing or have you in the recent past seen a therapist of counselor for any reason?

Have you ever experienced depression in the past or currently?

What are long-term or short-term emotional or mental challenges for you?

What are your major sources of stress? How do you react to stress? What helps you decompress and recharge in stressful times?

Do you have a spiritual practice of any kind? Going to church, temple, meditation, prayer etc. Please explain.

Diet & Nutrition

How is your digestion? Do you have trouble after eating? Bloating, gas, acid reflux, burning, nausea, heaviness, etc.?

Do you have a special diet (i.e. like vegan, vegetarian, fruitarian, raw foods etc.)?

How much water do you consume in a day? What about other drinks?

Do you eat in fast food restaurants or do you eat frozen and canned foods?

Do you use artificial sweeteners or have foods or drinks that contain them?

Do you drink carbonated beverages, like soda or bubbly water?

List any food allergies or sensitivities that you (may) have.

Please list what your diet is like on a given day, including beverages. List what you eat for breakfast, lunch and dinner, including the times. Also list any snacks you eat and the time of day.

Ayurvedic Physical Examination Questions

Face Shape

Oval

Angular

Square

Round

Lines on forehead

Right vertical line(s)

Left vertical line(s)

Horizontal line

Sclera Color (white part of the eye)

White

Blue

Yellow

Red

Nose size

Small

Medium

Large

Nose bridge

Narrow

Medium

Wide

Lips

Thin

Medium

Thick

Neck

Long

Medium

Short

Skin Thickness

Thin

Medium

Thick

Physique

Slight/thin

Moderate

Stocky

Irregular

Bones

Narrow

Moderate

Stocky

Any additional notes/comments about your physical examination:

Anything else?

You have take an amazing step towards your wellness!

Please let me know if there is anything you would like to share that is not already covered in this form.

By checking this box I agree to the terms and conditions described in the Ayurveda Health Waiver

Thank you for taking the time to fill out this intake. The information you provide is confidential and will be read with attention and detail by me. I look forward to reviewing this with you and showing you ways Ayurveda can support and balance your life.