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. 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
Eyes
Sclera Color (white part of the eye)
Nose size
Nose bridge
Lips
Teeth
Neck
Hair
Skin Thickness
Skin Condition
Skin Temperature
Physique
Bones
Fingers
Nails

Anything else

You are on the path to bring your body, mind and soul back into balance.

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.