Ayurveda Medical Form

Ayurveda Medical Form

For the Ayurveda Doctor to know about your current health and medical history. This information is confidential.
Name*

First NameLast Name
Email*
example@example.com
Are you a registered guest with a room reservation?
Registered means you have completed the application and deposit payment to reserve the room.
Stay Dates: Fromdd/mm/yyyy* To: dd/mm/yyyy*.
If not registered, please indicate the proposed dates.
Ayurveda Package*
Sex*
Preferred Pronouns
Age*
Height*
Height in Feet' inches
Weight*
Weight in kg
Do you smoke?*

1 Pack/day2 Packs/day+3 Packs/dayNo
What is your caffeine intake?*

1 cup/day2 cups/day3 cups/day4+ cup/day
What are the caffeinated beverages you regularly consume?
i.e. coffee, soda, energy drinks
Do you drink alcohol?*

< 5 servings / week7 servings / week> 7 servings / weekNever
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 / week3 - 5 times / weekEverydayNever
What type of exercise do you do?
i.e. walking, running, yoga, swimming, dancing
How many hours do you sleep?*

Less than 5 hours5 - 6 hours7 - 8 hours9 - 10 hoursMore than 10 hours
What is the quality of your sleep? *
i.e. good, difficult to fall asleep, interrupted, dreams
Current Health Concerns or Symptoms*
When did the problem begin?*
What makes it better or worse?*
Treatments tried so far (allopathic, alternative)*
Medications and Supplements Currently Taking*
i.e. Blood Pressure, Cholesterol, Diabetes, Asthma, Heart Disease, COPD, Depression, Anxiety, Herbal Supplements
Past Medical History*

DiabetesHypertensionThyroid DisordersAshtma / AllergiesArthritis / Joint PainSkin Disorders (eczema, psoriasis, acne, etc)Digestive Disorders (constipation, acidity, IBS, gastritis, pancreatitis, etc)Liver / Gallbladder IssuesKidney / Urinary Tract IssuesHeart DiseaseNeurological Issues (migraine, neuropathy, etc)Autoimmune disordersCancerOther
Detailed Medical History *
Please specify the diagnosis or symptom, onset, severity, and if it is ongoing or resolved.
Recent Hospitalizations?*
Specify the diagnosis and month + year.
Surgical History*
Specify the year/date.
Recent Injuries? *
Specify the year/date, injury location, ongoing symptoms (if any).
Allergies (food, medications, environmental)*
Specify the type of reaction and severity.
Food Sensitivities (non-allergy reactions to food)*
Specify the symptom and severity.
Family Medical History*
i.e. Heart Attack, Hypertension, Diabetes, Cancer, Celiac, Heart Disease, High Cholesterol, Depression, etc.
Any issue with Urination, Prostate Health, or Libido:*
Menstruation*

RegularIrregularNormal flowLight FlowHeavy FlowNot Applicable
Menopause
If applicable, please specify onset, symptoms, severity, if ongoing, and if received treatment.
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?*

ExcellentGoodOkayCan ImproveStruggling
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 EnergyNormal EnergyLow Energy
What do you expect to gain from this retreat?
Consent

I declare that the information provided above is true to the best of my knowledge. I understand all the medical risks involved in this program and take fully responsibility of any unexpected consequences. I understand that Ayurvedic treatment focuses on holistic wellness and is not a substitute for emergency medical care.
Signature*

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Date*

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Date
Should be Empty:

Ayurveda Medical Form

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