Ayurveda Intake Form Name * First Name Last Name Birth Gender (male or female) Your Birthdate * MM DD YYYY What time were you born? * Your Age * Marital Status Married, Single, Divorced, Widowed Occupation * Do you have any allergies? * (ie, herbs, spices, or drugs) What are some of your wellness goals? * Do you engage in any activities that could compromise your health or would be considered "unhealthy"? Do you have any current health concerns or problems? Any significant family history of health problems? Please list what you typically eat for breakfast, lunch, and dinner Any special dietary needs? List any previous Ayurvedic treatments, if any Body Weight: (height in feet and inches, weight now, weight 1 year ago, and any weight gain or loss in the last 6 months?) Is your digestion... (pick one: good, fair or poor) Is your appetite... (pick one: strong, moderate, mild, or variable) In general how is your eating during the day? (pick one: strong, medium, low, variable) do you often feel heavy after eating? yes / no Do you often feel sleepy after eating? yes / no Do you have problems with: pick one: gas, flatulence, belching, bloating, heartburn, acid indigestion, reflux, or anything else? List any other foods (if any) that cause discomfort: Do your bowel movements tend to be: regular or irregular? How often do you have bowel movements? When do you usually have bowel movements? Stools are usually: pick one: soft, medium, hard, variable consistency Do you use enemas or laxatives? yes / no Do you have hemorrhiods? yes / no What is your diet like? non-vegetarian, mostly vegetarian, vegetarian, vegan, or something else? Which is your main meal? pick one: breakfast, lunch, or dinner Do you eat between meals? yes / no How much time do you take for breakfast lunch and dinner write out an estimated time for each: Do you sit for 3-5 minutes after finishing a meal? yes / no Do you feel you now have or had in the past an eating disorder? yes / no (if yes please explain more) How often do you eat leftovers? pick one: often, sometimes, rarely, almost never How often do you eat frozen foods? pick one: often, sometimes, rarely, almost never How often do you eat packaged / processed foods? pick one: often, sometimes, rarely, almost never How often do you eat cold foods and/or drinks? pick one: often, sometimes, rarely, almost never How often do you eat raw vegetables/ salads? pick one: often, sometimes, rarely, almost never How often do you eat red meat? pick one: often, sometimes, rarely, almost never How often do you eat spicy foods? pick one: often, sometimes, rarely, almost never How many times per week do you eat out in a restaurant or order take-out? How often do you microwave your food or drinks? pick one: often, sometimes, rarely, almost never About what percentage of your food is organically grown? How many soft drinks or diet soft drinks do you drink each week? What kind of water do you drink? (spring, tap, alkaline, kangen, etc) Is your sleep disturbed? pick one: not at all, somewhat, moderately, severely, very severely Do you take sleep aids? yes / no (if yes, what do you take?) What time do you usually go to bed? What time do you usually wake up? Are your bedtime and arising times regular from day to day? pick one: very regular, mostly regular, somewhat regular, mostly irregular How regular is your daily routine? For example: do you go to bed, get up, and eat your meals around the same time daily? pick one: very regular, somewhat regular, not very regular, very irregular How often do you exercise? pick one: regularly, occasionally, never Is your exercise: pick one: vigorous, moderate, light, none Do you practice meditation? yes / no How often? pick one: regularly, occasionally, never What kind? Do you take daytime naps? pick one: often, sometimes, rarely, almost never Do you travel a lot? yes / no How often do you: smoke, drink alcohol, drink caffeinated beverages Do you feel you take enough time for yourself? yes / no How many hours a day do you use a computer? How many minutes per day on a cell phone? Are you having work or family problems that are impacting your health? Do you regularly cleanse your energy / space? example like burning sage or polo santo? (answer yes or no. if yes, how do you clear your energy and home?) How would you describe your mood? example: even, or erratic, or calm or easily triggered, etc. Do you suffer from... Pick one or write anything else additional -anxiety, depression, anger, mood swings? Are you currently in psychological counseling? yes / no What direction does your house face? What side of the house do you enter? What direction foes your head of your bed point towards? Do you live near a power plant or high tension wires? yes / no Are you exposed to chemicals, pesticides, or other toxins on a regular basis? yes / no Have you recently painted or renovated your home or office? yes / no Thank you!
