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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.)

Overall Health Evaluation

What is your average stress level in a week on a scale of 1-10? 1 being very low stress, and 10 being very high stress.

Emotional Well-Being

Diet & Nutrition

Ayurvedic Physical Examination Questions

Face Shape
Facial Energy
Lines at nose & mouth
Lines on forehead
Sclera Color (white part of the eye)
Nose size
Nose bridge
Skin Thickness
Skin Condition
Skin Temperature

Anything else?

You have take an amazing step towards your wellness!

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.

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