Company

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Date

MM slash DD slash YYYY

Name

First Last

Age

Gender

Phone

City

What do you hope to get from this consultation?

Any health concerns in these areas? Please take your time as this is a detailed list. Check all that apply.

allergies to food or environment

aches and pains

anger

anxious

bad breath

bleeding easily

bloating

burning sharp pain

cold clammy hands

cold extremities

congestion

constipation

diarrhea

difficulty sweating

dry cough

dryness

dull depression

dull vague pain

edema

envy

excess body heat

excess body odor

excessive sleep

fearful

feeling irritable

frequent thirst

frequent urination

gas

greed/ attachment

heaviness

hemorrhoids

insomnia

interrupted sleep

judgmental/ critical

joint cracking or popping

joint pain

lack of appetite

lack of energy

lack of motivation

lethargy

loose stools

migraine

muscle twitching/ cramping/weakness

nausea/vomiting

restlessness

sinus congestion

stiffness

skin rashes/ hives/ acne

sinking stools

swelling/edema

tender to touch

tongue coating

very oily skin

prone to colds / cough

mental fogginess in morning

low or no appetite/ no taste for food

lack of inclination to work

feel exhausted physically and mentally

tendency for indigestion

feel the need to spit often

feeling of heaviness in body

feeling of blockage (congestion/ constipation/ lack of mental clarity)

Briefly describe any past or current major medical issues

For all the questions below, type your answers in free form. There is no specific format.

Medications/Supplements currently taking:

List any allergies

Bowel information: Provide your bowel log for the last few days. List the approximate times for bowels , were they loose or well-formed or like pebbles, did you strain to eliminate, any constipation, did it smell or stick

Digestion information: Provide details for the last 2 to 3 days. Did you feel hungry before breakfast, lunch, and dinner. After eating, do you feel any of the following - gas, bloating, reflux, nausea, indigestion, stomach pain, stomach uneasiness

Please answer the long questions in free form, providing as much relevant information as you wish. There is no specific format.

Mealtimes and Food Intake at Breakfast, Lunch, Dinner, and Snacks

For the last few days ( assuming that you have been following a home-based routine and not traveling etc), list the foods that you ate for breakfast, lunch, dinner, and snack and the approximate time of the meal. Include caeffine/ beverage

Alcohol / substance use : How often and what do you use?

Menstruation/Female Reproductive – Is cycle regular? How many days does period last? How heavy is the period? PMS or pain concerns? Fertility? If you have had childbirths or miscarriages, please list them . List any menopause symptoms.

Male Reproductive – Any concerns?

Sleep habits: For the last few days (assuming that you have been following your home-based routine),list your bed-time and wake-up time. How was the sleep quality. Did you have dreams and what kind?

Please list any major events in your life that have emotionally affected you:

Do you do yoga and/or other yoga practices like meditation and pranayama? Do you follow a spiritual practice?

What do you do for work?

What hobbies do you do have?

What do you do for exercise?

With whom do you live? How does that situation impact your health?

What is your education?

Blood Pressure (if available)

Weight

Weight changes over past year?

Height

Any Pain? Mention location/score

0 = no pain, 10 = worst pain

Please upload any relevant pictures of current issues (if there is a visual appearance )

Drop files here or

Max. file size: 2 GB.

I type my name here to 1) Acknowledge that the Ayurvedic recommendations I will receive is not a substitute for medical advice from a licensed medical professional 2) Acknowledge that my case may further be discussed with an Ayurvedic professional if needed and that the discussion will not reveal my name or contact information(Required)

I hereby acknowledge the same by checking the box(Required)

Confirm

Holistic health with ancient wisdom of food, herbs, and lifestyle to nourish the body and mind

Posha Ayurveda

Holistic health with ancient wisdom of food, herbs, and lifestyle to nourish the body and mind

I am excited that you are pursuing Ayurveda for your holistic health. Please answer the questions below to the best of your ability and it will help me ask you relevant questions during the intake. It is ok to leave some questions unanswered if you are not sure.

Imagine this: You, stepping into a life where vibrant health is your everyday norm.

PICTURE WAKING UP FEELING ENERGIZED, FREE FROM THE PRESSURES OF STRESS AND HEALTH CONCERNS THAT ONCE HELD YOU BACK.

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