• Todays Date
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  • Patient Information

  • Date of Birth*
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  • Program Information

  • Present Health

  • Rows
  • Childhood illnesses:*

  • Immunizations/vaccinations:*

  • Daily Routine (dinacharya)

  • Do you get up early?
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  • Do you go to bed early?
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  • Do you sleep during the day?
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  • Bowet movement associated with (choose those that apply).*

  • Do you delay or suppress any of the following?
  • Do you travel often? *
  • Do you self-massage with oil daily?*

  • Excercise

  • Eating Habits

  • Rows

  • Describe what you typically eat

  • Do you eat between meals?*
  • Do you eat meals at regular times?*
  • Describe your diet.*

  • If you are a nonvegetarian, please indicate the proteins you eat.

  • What taste(s) do you like to crave?*
  • Are there particular foods that create discomfort when you eat them?*

  • Miscellaneous

  • Are you allergic to any substances?*

  • Do you experience any of the following?*

  • Social History

  • Rows
  • As a child, did you experience any abuse or trauma?*
  • Type of abuse:*

  • For Men Only

  • Please indicate which of the following areas are troublesome (if any).

  • For Women Only

  • How many days does your menstrual period last?

  • Do you have any associated symptoms (before or during menstruation?
  • Do you have any discharge outside of your menstrual period?
  • Do you ever experience pain during intercourse?
  • Are you pregnant now?
  • Do you have any sexual difficulties?
  • Do you take contraceptive pills or use other forms of birth control?
  • Do you breast self-exam regularly?
  • Do you experience any of the following?

  • 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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