Patient Extensive Intake Form

Patient Extensive Intake Form

An extensive Patient Intake Form. Form Preview
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  • Patient Information

  •  -  - Pick a Date
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  • Program Information

  • Present Health

  •   Child Myself Father Mother Brother(s) Sister(s) Spouse Other
    Age (if living)
    Age (at death)
    Cause of death
    Anemia
    Cancer
    Diabetes
    Epilepsy
    Glaucoma
    Hearth Disease
    High Blood Pressure
    Hay Fever
    Hives
    Kidney disease
    Mental illness
    Rheumatoid arthritis
    Tuberculosis
    Syphilis
    Stroke
    Other


  • Daily Routine (dinacharya)

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  • Excercise

  • Eating Habits

  •   Daily Weekly Monthly Never
    Grains/cereals
    Vegetables
    Fruits
    Dairy
    Eggs
    Poultry
    Meat (beef, pork, etc.)
    Seafood
    Sugar/Honey
    Desserts
    Juices
  • Describe what you typically eat



  • Miscellaneous


  • Social History

  •   Excellent Good Fair Poor
    How are your family relationships?
    How is your social life?
    How is your mental health?
    How is your career?
    How purposeful is your life?
    Rate your spiritual life.

  • For Men Only

  • For Women Only



  • I understand that this is an educational Ayurvedic consultation for the purpose of helping me improve my health and wellness. I understand this does not include medical diagnoses or treatment and is not a substitute for medical care or an agreement for ongoing care.

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