Ayurveda Medical Form
For the Ayurveda Doctor to know about your current health and medical history. This information is confidential.
Are you a registered guest with a room reservation?
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
If not registered, please indicate the proposed dates.
Height in Feet' inches
Weight in kg
Do you smoke?
What is your caffeine intake?
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
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
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
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.
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.
Are you Pregnant
Are you Lactating
Do you plan on getting pregnant in the next year?
Fertility Medical History (if applicable)
How would you rate your current Health?
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?
What do you expect to gain from this retreat?
Should be Empty:
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