Ayurvedic Intake Form

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1 Ayurvedic Intake Form Name: Today s Date Date of birth: Time of birth: Place of birth: Place of childhood: Other Places lived: Current address: Home phone: Work phone: address: Occupation: Age: Sex: Height: Weight: Living situation: Spouse Partner Alone Friends Parents Children Emergency contact: Phone: Spouse Parent Friend Other (specify) Main health concerns and intentions: Origins, duration and progress of the symptoms of main concerns: Past treatments :

2 Please check any recent or chronic concern: Respiratory Cardiovascular Gastro-Intestinal congestion high blood pressure constipation dry cough low blood pressure diarrhea allergy poor circulation indigestion asthma pain in the heart gas chronic cough stroke bloating wheezing sinus infection sore throat nausea vomiting ulcers blood in stools Skin Muscles/Joints Urinary/Kidneys dry skin muscle twitching excessive urination acne muscle weakness kidney stones skin rashes, hives muscle cramping water retention/edema bruises joint stiffness painful urination joint swelling blood in urine muscle/joint pain, inflammation General low energy anxiety, nervousness excessive appetite fatigue low appetite depression, lethargy insomnia stress anger

3 Reproductive Female Age of first cycle heavy bleeding pain with menses length of cycle bleeding between periods bloating before menses pms blood clots irregular periods painful intercourse breast lumps breast pain vaginal discharge vaginal dryness hot flashes mood swings infertility vaginal itching ovarian cysts fibroids abnormal PAP smear cancer hysterectomy endometriosis Birth control method: Have you ever been on a birth control pill? If yes, what kind? Please list pregnancies, miscarriages and abortions you have had: Reproductive Male burning/discharge painful testicles infertility vasectomy lumps/swelling of testicles

4 Are you currently seeing any health care providers? Yes No If yes, please list their names and the reasons you are seeing them: Are you familiar with Ayurveda? Please list any dietary supplements, vitamins, herbs you are currently taking: Name Reason Quantity Please list any medications you are currently taking: Name Reason Quantity

5 Health History Please list any medications, herbs, foods you are allergic to: Please list any previous serious conditions including operations: Condition Year Please list all serious health conditions in your family and your relation to that person:

6 Diet and Lifestyle How is your appetite? Diet: vegetarian non-vegetarian other (please explain) Please describe your meals including times of the day and food choices: Breakfast: Lunch: Dinner: Snacks: Liquid intake, in cups: caffeinated beverages juice water/herbal teas dairy other

7 Do you have any food cravings? Do you have any addictions? smoking drugs alcohol Bowel habits: Urinary habits: Sleep habits: Stress level: Exercise routine: According to Ayurveda the frequency of sexual activity may have an impact on health. Please indicate how often you engage in sexual activity: daily several times a week several times a month occasionally never Please describe your daily routine/activities: Morning: Day: Evening/Night:

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