Seva Ayurveda Health Intake form
Today's Date
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Month
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Day
Year
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Name
First Name
Last Name
Date of Birth
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Month
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Day
Year
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Gender Identity
Male
Female
Other
Pronouns (ex. she/her/they etc.)
Height
Weight
Phone Number
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Area Code
Phone Number
City, State
Email
Have you suffered from or been diagnosed with any conditions?
Current Health Concerns and Symptoms:
What are your current health goals you would like help to reach?
List any Prescription Medications and Dosage
List any Herbal or Alternative Medicine, Dosage, and Frequency
Do you want to learn more about CBD?
Family Health History
Please list any diseases or health issues
Mother
Father
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Daily Routine
Exercise and Frequency:
How long does it take before you break a sweat?
Morning - (Time you wake up, what do you do upon rising, etc..)
Afternoon
Evening - (Especially between 7p-12a)
Meals
Rate on a scale of 0-10 how hungry you feel at meal times
0-Not at all 1-3 - Mildly Hungry 4-7 Moderate 8-10 Quite to Very Hungry!
Does your food get digested well on some days and sometimes not?
Which extreme of weather are you unable to tolerate?
Which tastes do you prefer? i.e. sour, salty, sweet, bitter, spicey
Breakfast - Please list food taken and time range
Lunch - Please list food taken and time range
Dinner - Please list food taken and time range
Snacks - Please list foods taken and time range
Elimination Patterns - Please list the time and frequency of your bowel movements as well as the quality and texture (i.e. constipation, loose, dry, moist, broken, etc....refer to Bristol Stool Chart Below) and Frequency of Urination
Sleeping Patterns - List time you go to sleep, difficulty falling asleep or staying asleep? Time you wake up?
Please indicate below
any symptoms you have e
xperienced in the last three m
onths:
Skin Texture
Hives
Pimples
Large Pores
Other
Rashes
Recent moles
Skin tags
Loss of hair
Itching
Dandruff
Head
Dizziness
Migraines
Other head/neck problems:
Facial pain
Headaches
Eyes/Ears/Mouth
Glasses
Blurry vision
Poor hearing
Grinding teeth
Poor vision
Color blindness
Ear aches
Recurrent sore
Cataracts
Eye pain
Nose bleeds
Eye strain
Spots in vision
Sinus problems
Sores on lips or tongue
Night blindness
Ringing in ears
Teeth problems
Jaw clicks
Circulation
Swelling of feet
Chest pain
Blood clots
Other problems with heart
Low blood pressure
Fainting
Cold hands
Difficulty breathing
Swelling of hands
Irregular heartbeat
Venous swelling
Cold feet
Dizziness
Respiratory
Cough
Pain with deep breath
Phlegm color:
Coughing blood
Difficulty lying down
Musculoskeletal
Neck pain
Hand/wrist pain
Foot/ankle pain
Other:
Back pain
Hip pain
Other muscle pain
Shoulder pain
Knee pain
Muscle weakness
Gastrointestinal
Nausea
Gas
Blood in stools
Other problems
Vomiting
Belching
Black stools
Diarrhea
Indigestion
Abdominal pain/cramps
Constipation
Bad breath
Chronic laxative use
Other
Urinary
Frequent
Urgency to urinate
Kidney stones
Wake up to
Unable to hold urine
Impotency
Decrease in flow
Excessive
Blood in urine
Pain on Urination
Wake up to Urinate
Reproductive
Painful periods
Use birth control
No. of Pregnancies:
Length and Duration of Menstrual Cycle: (If irregular please describe)
No. of Miscarraiges/Abortions
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