Ayurveda Medical Form
For the Ayurveda Doctor to know about your current health and medical history. This information is confidential.
Name
*
First Name
Last Name
Email
*
example@example.com
Are you a registered guest with a room reservation?
Please Select
Yes, I received the booking confirmation from ashram.
No, I am planning to register.
Registered means you have completed the application and deposit payment to reserve the room.
Stay Dates: From
dd/mm/yyyy
*
To:
dd/mm/yyyy
*
.
If not registered, please indicate the proposed dates.
Ayurveda Package
*
Please Select
Panchakarma (detox)
Rasayana (rejuvenation)
Stress Management
Weight Management
Other
Sex
*
Please Select
Female
Male
Intersex
Preferred Pronouns
Please Select
She/Her
He/His
They/Their
Age
*
Height
*
Height in Feet' inches
Weight
*
Weight in kg
Do you smoke?
*
1 Pack/day
2 Packs/day
+3 Packs/day
No
What is your caffeine intake?
*
1 cup/day
2 cups/day
3 cups/day
4+ cup/day
What are the caffeinated beverages you regularly consume?
i.e. coffee, soda, energy drinks
Do you drink alcohol?
< 5 servings / week
7 servings / week
> 7 servings / week
Never
What is your main type of alcohol beverage?
i.e. beer, wine, spirits
Do you take recreational drugs? If so, what kind?
*
How often do you exercise?
*
1 - 3 times / week
3 - 5 times / week
Everyday
Never
What type of exercise do you do?
i.e. walking, running, yoga, swimming, dancing
How many hours do you sleep?
*
Less than 5 hours
5 - 6 hours
7 - 8 hours
9 - 10 hours
More than 10 hours
What is the quality of your sleep?
*
i.e. good, difficult to fall asleep, interrupted
Current Health Concerns or Symptoms
*
Medical History
*
i.e. Hypertension, High Cholesterol, Diabetes (type I or II), Asthma, Heart Disease, Heart Attack, Stroke, COPD, Thyroid, Celiac, Crohn's, IBS, IBD, Diverticulosis, Psoriasis, Eczema, Cancer, Depression, Anxiety, Bipolar, Schizophrenia, etc.
Surgical History
*
Allergies (food, medications, environmental)
*
Medications and Supplements Currently Taking
*
i.e. Blood Pressure, Cholesterol, Diabetes, Asthma, Heart Disease, COPD, Depression, Anxiety, Herbal Supplements
Family Medical History
*
i.e. Heart Attack, Hypertension, Diabetes, Cancer, Celiac, Heart Disease, High Cholesterol, Depression, etc.
Menstruation
Regular
Irregular
Normal flow
Light Flow
Heavy Flow
Not Applicable
Are you Pregnant
Please Select
Yes
No
Not Applicable
Are you Lactating
Please Select
Yes
No
Not Applicable
Do you plan on getting pregnant in the next year?
Please Select
Yes
No
Not Applicable
Fertility Medical History (if applicable)
How would you rate your current Health?
*
Excellent
Good
Okay
Can Improve
Struggling
How do you rate your current level of Stress?
*
1-10 with 1 = almost none, 10 = very high stress
How do you rate your current Energy or Vitality?
*
High Energy
Normal Energy
Low Energy
What do you expect to gain from this retreat?
Submit Survey
Should be Empty: