Todays Date
Month Day Year
Patient Information
Patient Name*
First Name Middle Name Last Name
Date of Birth*
Month Day Year
Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
Home Phone*
Area Code Phone Number
Work Phone
Area Code Phone Number
Cell Phone*
Area Code Phone Number
Patient E-Mail*
Current Occupation*
Emergency Contact*
Relationship to Patient*
Emergency Contact Phone Number*
Area Code Phone Number
Program Information
Why are you interested in an Ayurvedic consultation?*
Present Health
Please describe your present health problems and their duration.*
How long have you had the chronic conditions about which you are consulting us?*
How have your health problems progressed since they began?*
Please indicate the overall intensity of your symptoms.*
Do you take any nonprescription drugs, vitamins and/or any other supplements? Please list them.*
Are you currently under the care of a family physician or any other health professional? If yes, include details.*
Do you currently take medication and/or receive medical treatment for your health condition(s)? If so, include all medications, treatments, and dosages.*
Do you have any past medical history or problems (i.e.. illness, trauma, emotional stress, addictions, drug abuse, or anything else that will help us clearly understand your health condition)?*
Is there a family history of the health problem(s) listed above? If yes, please specify.*

Fill in as appropriate

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

Any other family illnesses or concerns? If yes, please specify.*
Health as a child:*
Childhood illnesses:*
German measles Measles Mumps Bronchial problems Scarlet fever Diphtheria
Immunizations/vaccinations:*
Smallpox Polio Typhoid Mumps Tetanus Influenza
Have you ever experienced a reaction to vaccination(s)? If yes, please specify.*
Daily Routine (dinacharya)
Do you get up early?
Yes No
At what time?*
: Hour Minutes AM/PM Option
Do you go to bed early?
Yes No
At what time?*
: Hour Minutes AM/PM Option
Do you sleep during the day?
Yes No
At what time?*
: Hour Minutes AM/PM Option
How do you generally feel when you wake up in the morning?*
In what direction does your head point during sleep?*
How would you describe your experience of sleep?*
What position do you sleep in?*
How regularly do you follow your ideal routine (i.e., go to bed early, eat meals on time, exercise regularly)?*
Describe your bowel movements.*
Other, please specify
Bowel nature:*
Bowet movement associated with (choose those that apply).*
Pain Blood Mucous Foul Smell
Do you delay or suppress any of the following?
Sleep Bowel movements Gas Urination Yawning Burping Thirst Breathing Semen Hunger Sneezing Tears
Do you travel often?*
Yes No
Do you self-massage with oil daily?*
Yes No
Excercise
How often do you excercise?*
What type of exercise do you do?*
How long do you excercise each time?*
Rate the intensity of your excercise.*
Eating Habits
Choose the answer that best describes your 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
Breakfast*
Lunch*
Dinner*
Snack*
Do you eat between meals?*
Yes No
Do you eat meals at regular times?*
Yes No
Which is your biggest meal?*
Rate your digestion.*
How much water do you drink per day?*
Indicate your eating habits.*
Describe your diet.*
Vegan Lacto-vegetarian Lacto-ovo vegetarian
If you are a nonvegetarian, please indicate the proteins you eat.
Beef Pork Chicken Turkey Seafood Eggs
Indicate which best describes your sense of taste (if any).*
What taste(s) do you like to crave?*
Sweet Salty Sour Bitter Hot/Spicy Starches Oily
Are there particular foods that create discomfort when you eat them?*
Sweet Salty Sour Bitter Astringent Dairy Products (including cheese)
Miscellaneous
Do you practice any type of meditation? If yes, please explain.*
Do you practice yoga? If yes, please explain.*
Which type of weather makes you feel most uncomfortable?*
Are you allergic to any substances?*
Food Pollen Dust
If you smoke cigarettes (or other substances), how many do you smoke per day?
How often do you drink alchohol?*
How much at at time?
How often do you drink caffeinated beverages?*
How would you rate your usual energy level?*
Do you experience any of the following?*
Depression Anxiety Fear or panic Loneliness Worry High stress level Anger Lack of memory Light-Headedness Lack of energy Suicidal thoughts or attempts Irritation
Social History

Select the best answer for the the questions asked.*

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.

As a child, did you experience any abuse or trauma?*
Yes No
Type of abuse:*
Emotional Physical Sexual Verbal
For Men Only
Please indicate which of the following areas are troublesome (if any).
Hernias Sexual difficulty Urination Erection problem Libido Birth control Prostrate problems Discharge or sores Venereal disease Testicular masses
For Women Only
Age menses began:
Which of the following describes your menstruation?
How many days does your menstrual period last?
1-4 days 5-7 days More than 1 week Irregular throughout the month
How is your menstrual flow?
Do you have any associated symptoms (before or during menstruation?
None Pain Fluid retention Migraine Depression Acne Tension Nightmares Frustration Loneliness
Do you have any discharge outside of your menstrual period?
Yes No
Do you ever experience pain during intercourse?
Yes No
Are you pregnant now?
Yes No I don't know
Do you have any sexual difficulties?
Yes No
If yes, please explain.
Do you take contraceptive pills or use other forms of birth control?
Yes No
If yes, please explain.
Number of previous pregnancies.
Do you have any history of abortion, miscarriage, or problems related to pregnancy or labor? If yes, explain.
How many children do you have?
How old are your children?
Do you breast self-exam regularly?
Yes No
Do you experience any of the following?
Pain or tenderness Lumps Nipple discharge
Other comments
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.
Client Signature*
By signing you agree to the conditions stated above Clear
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Patient Information

Program Information

Present Health

Daily Routine (dinacharya)

Excercise

Eating Habits

Describe what you typically eat

Miscellaneous

Social History

For Men Only

For Women Only