Name
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First Name
Last Name
Today's Date
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Age
Height
Male/Female/Other
Weight
Does your weight fluctuate? If yes, please provide details:
Date of birth
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Time of birth?
Place of birth?
Occupation
Address
Phone
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Email
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Why are you interested in an Ayurvedic consultation?
Please list any prescription drugs you are currently taking, and how much per day
Please list any non-prescription drugs, vitamins or any other supplements you are currently taking, and how much per day
Are you currently under the care of a physician, or any other health professional? If yes, please provide details:
Do you have any past medical history or problem, not mentioned above? If yes, please provide details:
Is there a family history of health problems? If yes, please provide details (example: Father, Mother, Brothers, Sisters, Spouse, Child, other):
Have you experienced any traumas, major illnesses or stress? If yes, please provide details:
Please describe your health as a child
Have you had any surgeries? If yes, please provide details:
What time do you go to bed?
Do you sleep in the day time?
How do you feel upon awakening in the morning (rested, tired, groggy etc)?
Please describe your sleep (example: sound, deep, awake often, light, nightmares, not enough sleep)
Bowel movement frequency (example: not every day, once a day, 2-3 times a day, first thing in the morning, after meals etc)
Please describe your bowel movements: soft, medium, hard, floating, sinking, color, smell
Do you delay or suppress any of the following: sleep, thirst, bowel movements, gas, urination, burping, hunger, yawning, tears
Do you travel a lot?
How long do you exercise each time?
What type of exercise?
How would you describe it: vigorous, moderate, light
Please describe a typical breakfast for you:
What time do you eat lunch?
Please describe a typical lunch for you:
What time do you eat dinner?
Please describe a typical dinner for you:
Do you snack during the day?
If yes, what do you eat for a snack:
Which is your biggest meal of the day:
How much water do you drink in a day:
Describe your eating habits (do you eat fast, without much chewing; do you eat thoughtfully and slowly; eat with full attention, with no distractions; eat while watching TV or phone; eating standing up):
Describe your diet (vegan, vegetarian, meat eater):
What tastes do you crave/prefer: sweet, sour, salty, bitter, spicy
Are there any foods that cause discomfort for you when you eat them? If yes, please list the food item and symptom:
How often do you consume the following:
Takeout
How often do you consume the following:
Spicy Food
How often do you consume the following:
Refined Sugar
Do you find time to relax, get outside etc? If yes, please provide details:
What type of weather do you prefer? Please provide details:
Do you have any allergies? If yes, please provide details:
Do you smoke or vape? If yes, what do you smoke and how often:
Do you consume alcohol (this would also include Kombucha)? If yes, how often and how much:
Do you consume caffeinated beverages (coffee, tea, soda)? If yes, how often and how much:
How would you describe your energy level: very high, high, moderate, low, very low
Do you often experience any of the following: worry, depression, lack of energy, anxiety, fear, anger, irritation, stress
Age menstruation ended (if applicable)?
Please describe your menstruation (example: regular, irregular, heavy, light, absent etc)
How many days does your menstrual period last?
Any symptoms before, during, after your period? (example: none, pain, acne, migraine, depression, cramps etc) If yes, please describe:
Do you experience any sexual difficulties?
Are you pregnant now?
Do you take contraceptive pills or use other devices? If yes, please provide details:
Number of previous pregnancies:
Do you have a history of abortion, miscarriage, etc? If yes, please provide details:
How many children do you have? Please list their ages:
Do you experience any problems in your breasts (example: tenderness, lumps, other)
Any other comments:
