Inspired By Ayurveda Intake Form

SECTION 4: Daily Routine & Activities
What are your main interests and hobbies?
What is your experience with meditation, yoga or breath work? How often and what does this look like?
List practices and frequency or if you are new to yoga.
How much time can you dedicate to a personal (at home) daily yoga & meditation practice?

15 minutes30 minutes45 minutes60 minutesOther
Do you exercise regularly? Describe.
What other movement/activities do you enjoy (dance, martial arts, qigong)?
How many hours do watch TV weekly?
How many hours are you on social media weekly?
Sleep
Do you have problems falling or staying asleep?

YesNo
What time do you go to sleep?

:HourMinutesAM/PM Option
How many hours do you sleep?
Do you awaken regularly in the middle of the night, if yes, what time?
Yes/No: TIME
Do you take naps & if yes, what time?
Yes/No: TIME
What time do you wake & stay up?

Rate your stress level: 1-10

	1	2	3	4	5	6	7	8	9	10

1 is low, 10 is high

Rate your energy level: 1-10

	1	2	3	4	5	6	7	8	9	10

1 is low, 10 is high

Rate your happiness level: 1-10

	1	2	3	4	5	6	7	8	9	10

1 is low, 10 is high

Rate your mood level (1=gloomy/bad ; 10=cheerful)

	1	2	3	4	5	6	7	8	9	10

1 is low, 10 is high

Rate your emotional expression level (1=I keep things to myself ; 10=I always say and FEEL my emotions)

	1	2	3	4	5	6	7	8	9	10

1 is low, 10 is high

(scroll to right)

How hungry are you throughout the day?

	1	2	3	4	5	6	7	8	9	10

1 is low, 10 is high

What time do you eat throughout the day?
What is a typical day's food intake? Please list all meals, beverages and snacks.
BREAKFAST: SNACK: LUNCH: SNACK: DINNER: SNACK:
How many ounces of water do you drink daily?
What is your bowel frequency?
List food allergies or foods you avoid and what reason.
What past struggles and difficulties have you experienced in terms of food and dieting?
Chronic snacking or overeating, eating late at night, I don't cook, I eat fast food regularly, food nutrition is too complex, gluten intolerance, other food intolerances, etc.
What diet protocols/plans/approaches have you tried in the past that have worked?
i.e keto, vegetarian,
My meals are:

VeganVegetarianLow Carb / High ProteinPescetarianOther
I consume as a regular part of my weekly meals:

Fast foodsFrozen foodsFast foodsLeftover foodsPrepackaged foods (including can, pre-cooked)Restaurant (take out or dine-in)
Current Picture of Your Health
Which describes your current state of health?

1. Multiple health issues & w/meds2. Minor health issues & w/meds3. Health issues & no meds4. Minor discomforts5. Healthy but always learning to improve my health
List diagnosed chronic medical conditions, surgeries and hospitalizations:
i.e.: high/low BP, asthma, depression, anxiety, PTSD, diabeties, cancer, etc.
List medications, supplements or herbs you currently take regularly:

Health History

	No, never	Yes, currently	Not currently, but yes within the last year
Fatigue
Unexplained weight loss or gain
Change in appetite
Depressive symptoms
Anxiety
Mood swings
Nervousness
Addictive dependency
Disordered Eating Pattern/Tendency
Tension
Lack of mental focus
Diabetes
Blood sugar irregularities
Excessive thirst or hunger
Sugar cravings
Excessive perspiration
Feeling excessively hot or cold
Lightheadedness
Joint pain or stiffness
Muscle weakness or soreness
High blood pressure
Cold or pale extremities
Asthma
Short of breath
Heartburn
Abdominal discomfort after eating
Nausea
Abdominal bloating
Belching/gas
Migraines

SECTION 6: For Yoga STUDIO Clients Only
What are your yoga class interest?

RelaxationBreathwork/pranayamaMeditationStrength & enduranceKundalini YogaSpiritual growth
What type of classes, and day(s)/time of day would you like to see additional classes on the schedule?

SUBMIT FORM
Additional information you would like to share?
I would like more information regarding:*

Private Consultation (in person or zoom)Private Yoga/Meditation Sessions (in person or zoom)Ayurvedic TreatmentsAyurvedic Lifestyle Workshops & Classes21-Days to a New You: Mind-Body-Spirit ResetAyurvedic Yoga Retreats (India, Regional, Local and abroad)Nothing TodayOther
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