Ayurvedic Intake Confidential Client History (Fields marked with a * are required.) Step 1 of 3 33% Basic informationName* First Last Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Home phoneDaytime phone*AgeBirthdate MM slash DD slash YYYY Birth time : Hours Minutes AM PM AM/PM Birthplace Gender Male Female Marital/partner status Children? Yes No How many children?Childrens' ages Please enter one child's age, then press the (+) to add more.Birth complications for each child or normal?Current or past history of the following: Serious injuries Trauma (mental/physical) Emotional stress Lifestyle issues Large change in weight Unusual aches/pains Fatigue for longer than one month Mental clarity/concentration Hot flashes/night sweats Visual issues Cosmetic surgery Chronic headaches Hysterectomy Perimenopause Postmenupause (Check all that apply.)Please describe any of the above checked items:State your goals for this consultation.*Describe your current health issues.Hospitalizations/surgeries?ReasonDate Press the (+) to add more lines.Have you seen a health care practitioner in the past year?* Yes No Why?Date/results of last exams if apply: DXA; Mammography; Colonoscopy; Cardiac Workup, etc.ExamDate Press the (+) to add more lines. Medical historyPlease check any of the following that pertain to you or have occurred on your Maternal or Paternal sides of family (siblings, parents, grandparents)Allergies (food/meds/environ) Please list any allergies here. Click the + to add new fields.Kidney/Bladder infection Myself Maternal Paternal Mental issues: anxiety, depression, bipolar Myself Maternal Paternal Gallbladder/Liver Myself Maternal Paternal Prolonged bleeding when cut Myself Maternal Paternal Rheumatic fever Myself Maternal Paternal Shortness of breath Myself Maternal Paternal Stroke/Cerebral vascular accident Myself Maternal Paternal Thyroid issues/meds Myself Maternal Paternal Ulcers/intestinal bleeding Myself Maternal Paternal Sexually transmitted disease Myself Maternal Paternal Skin irritations/breakouts Myself Maternal Paternal Chronic grief/sadness Myself Maternal Paternal Please briefly describe anything above checked:Current Lifestyle PatternsMovement/exerciseTypes:Times per week:Average length of time: Please click the + too add a new row.Spiritual practicesTypes:How often: Please click the + too add a new row.Addictive substances (caffeine, cigarettes, marijuana, pain pills):Types:How often:If quit, when? Please click the + too add a new row.Work or schoolTypes:Stress:Satisfaction: Please rate stress and satisfaction on a scale of 1 to 5, with 5 being the highest. Please click the + too add a new row.Primary intimate relationshipTypes:Stress:Satisfaction: Please rate stress and satisfaction on a scale of 1 to 5, with 5 being the highest. Please click the + too add a new row.Sexual activityTimes/month:Pain?:Satisfaction: Please rate pain and satisfaction on a scale of 1 to 5, with 5 being the highest. Please click the + too add a new row.Morning activitiesTypes:Time awaken, self care:Wakes refreshed or tired/sluggish? Please click the + too add a new row.Afternoon activitiesTypes:Time eat, nap, other:Time eat: Please click the + too add a new row.Evening activitiesTypes:Time eat:Time to bed: Please click the + too add a new row.Diet/digestion/appetiteSpecific eating routines:Current/past chronic eating disorders/issues:Known allergies or food sensitivities, problem foods: Press the (+) to add more lines.Food/drinkWater cups/day:Non-caffeine cups/day:Caffein cups/day:Snacks/day:AlcoholDrinks/dayDrinks/weekType of alcoholRecent changes?Do you have a history of acid indigestion/reflux? Yes No What helps? Daily profile(Check all that apply)Vata Pitta KaphaHunger levelVariableStrongLowWhen miss mealsAnxious/lightheadedIrritableNot significantTypical meal sizeMedium/variesLargeSmallFrequency of mealsIrregularRegularRegularEating speedQuickMediumSlowResponse after eatingGas, bloating, belching, painHeartburn, acid indigestion, smelly gasHeavy, sluggish, sleepy, nausea, vomitingTiming of eating response2+ hours after eating1 hour after eatingImmediateBowel movements< 1x/day2+x/day1x/dayBowel movement typeConstipationLoose, unformedThick/sluggishBowel movement consistencyDry, pellets, food particlesBloody stool, unusual colorOily, muscousyUrine colorClear to light yellowYellow to dark yellowSlightly cloudyUrine frequencyVery frequent or very littleEvery 1-2 hoursEvery 1-2 hoursUrine issuesNo urge for several hours, or frequentlyBurning with peeDoes not feel complete after peeBody temperatureCold, variesWarm to heatedCoolSweating/perspirationVery littleModerate to strongModerateOdor of sweatVery littleStrong/pungentSweetSkinDryOilyMoist/clammyPerimenopause/Menopause? Yes How many years?Menses cycleIrregular/variesRegularRegularMenses flowLight/variesHeavyModerate/heavyMenses discomfortPainfulModeratePainlessSleep typeLightMediumDeepStaying asleepFalls asleep/wakes in the nightChallenge to fall asleep. Once asleep, sleeps all nightEasy to fall asleep, stay asleep, difficulty wakingDreamsFearful, anxious, movementIntense, angry, violent, adventureFlowing, easyPersonality profilePlease check what fits you now.Vata Pitta KaphaMy descriptionDo things on my ownLeaderFollowerReaction to stressOverwhelmed, scatteredStep up to the challenge, create a planEasy to moderateDecision makingFast, change mindFast, stick to itSlowThoughtsQuick mind, restlessSharp, focusedCalm, steadyProjectsGreat beginner, may not finishCreate a plan, finish on timeSlow, but always finishMemoryForgetfulGoodCalm, steadyAbility to focusShort term bestGreatGood long term focusSpeech patternFast, ramblesClear, concise, sharpSlow, quiet, pleasantRelationshipsMany acquaintancesIntense/focusedLong standingPlease take time to further describe anything else you would like me to know:List all current medications, supplements or herbsProductType (prescription, herb, supplement)PurposeHow long?Current dosage PhoneThis field is for validation purposes and should be left unchanged. 13246