Client Intake Form - Initial visit
Information provided by client is strictly confidential
and preferred gender pronouns
Date of Birth
Location of Birth
Time of Birth
Do I have permission to look at your birth chart?
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
How did you hear about our services?
Emergency Contact Phone Number
Please enter a valid phone number.
Personal Health History
Reason(s) for consult. (Please include how long you have been experiencing each concern)
What things, if any, have you already tried to address the health concerns you are having?
What health goals would you like to achieve?
Are you familiar with Ayurveda and what do you hope to gain through services?
In the past 12 months, describe your experience with the following:
Expectations of Yourself
Expectations of Others
Overall Perception of Self
Overall Perception of Life
Anything else you would like to share?
Allergies and/ or sensitivities (Medicines, foods) Please include the reaction that you experience
Dietary Preferences (ex. Vegetarian, Vegan, Gluten Free, Dairy Free etc.)
Current medications, supplements, vitamins, herbs, etc. Please include name, dosage, purpose, and frequency for each.
Surgeries or hospitalizations. Please include approximant date and reason
Have you had any lab work or blood work done recently? If so, any concerns with your results?
Please describe your childhood experience.
Do you have any religious or spiritual preferences or practices?
Family Health History
Cancer or tumors
Anemia or blood disorders
High blood pressure
Low blood pressure
Allergies or asthma
Chronic body pain ( Back, R/A)
Respiratory/ breathing issues
Abuse (physical, sexual, emotional)
Age of death, if applicable
Any important family health history that was not addressed above?
Personal Health Habits
When do you go to sleep?
When do you wake?
Do you have issues going to sleep or staying asleep?
Do you wake in the middle of the night? What times? How often?
Do you feel rested after sleeping? Do you struggle to get out of bed?
Do you dream? If so, describe typical content of dreams.
What is your relationship to food?
Describe your appetite.
Do you follow a regular eating routine?
Describe your thirst.
What is your favorite thing to eat?
What is your favorite thing to drink?
Breakfast time and foods for the past 3 days.
Lunch time and foods for the past 3 days.
Dinner time and foods for the past 3 days.
Snack time(s) and foods for the past 3 days.
What throws off your routine?
How important is routine to you?
Do you feel you have an addictive personality?
What do you crave most?
Do you eat sugar regularly? If so, what and how often?
Do you drink alcohol? If so, what and how often?
Do you smoke tobacco? If so, what and how often?
Do you smoke or ingest marijuana? If so, what and how often?
Do you drink coffee, tea, or caffeinated beverages? If so, what and how often?
Do you use any recreational drugs? If so, what and how often?
Are you interested in help with any of the above substances?
Types of exercise
How often do you poop?
Describe poop? (hard to pass, easy to pass, urgent, loose, hard, dark, light, complete/ incomplete, messy, etc.)
Frequency of urination during the day?
Do you urinate during the night?
Describe your urine. (Color, smell, etc.)
Do you have difficulty or pain urinating?
Force in urination decreased
Difficulty emptying bladder
Have you had a kidney, bladder, or prostate infection in the last 12 months?
Are you sexually active?
Libido (low, medium, high)
Difficulty experiencing orgasm? Difficulty getting/ maintaining an erection?
Date of last personal wellness exam?
Age of onset of mensuration. Perception of experience:
Date of last menstruation
Do you track your cycles?
Regular or irregular cycle?
days. Lasting for
Have you experienced?
If you could change something about your cycle, what would it be?
Are you pregnant?
Have you been pregnant, and how many times?
How many live births and additional info?
Describe each pregnancy:
Describe each birth:
How were you cared for after giving birth?
Any complications post pregnancy?
Are you trying to get pregnant currently, or in the next 12 months?
Are you interested in receiving Ayurvedic Doula services?
Are you peri or post menopausal? Date of last menses?
Symptoms associated with menopause?
Any sexual difficulty, if yes please describe?
Testicular pain, inflammation, masses, etc.
Discharge, tenderness, sores, hemorrhoids, etc.
Date of last prostate exam, if applicable.
Optional additional information
Any additional information you would like to provide?
Should be Empty: