Whole Body Wellness Ayurvedic Client Intake Form
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Male
Female
Age
Birthdate
Occupation
Marital Status
Are you ALLERGIC to, or intolerant of, any HERBS, SPICES, FOODS or DRUGS? Please list below:
What are your goals for your wellness consultation today?
Do you currently engage in any activities that could compromise your health or would be considered “unhealthy”?
Do you have any current health concerns or problems?
Any significant family history of health problems?
Please list all prescription medications, birth control pills, hormone replacement therapy, vitamins or other supplements that you are taking:
Foods you typically eat (Breakfast, Lunch, Dinner, Snacks)
Any special dietary needs?
Previous Ayurvedic evaluations and treatments:
List date and place of most recent previous Ayurvedic evaluation, or in-residence Ayurvedic programs, if any:
Body Weight
Height (ft' in")
Weight (Now)
Weight (1 year ago)
Maximum / when?
Minimum / when?
Any weight gain or loss in the past 6 months? (# of pounds, + or -)
Digestion
Is your digestion
Good
Fair
Poor
Is your appetite
Strong
Moderate
Mild
Variable
In general, how is your energy during the day?
Strong
Medium
Low
Variable
Do you often feel heavy after eating?
Yes
No
Do you often feel sleepy after eating?
Yes
No
Do you have problems with
Gas
Flatuence
Belching
Bloating
Heartburn
Acid Indigestion
Reflux
Other
Are there any foods that cause discomfort?
Elimination
Do your bowel movements tend to be?
Regular
Irregular
How often do you have bowel movements?
More than 3 times a day
2-3 times per day
Once daily
Less than once every 3 days
When do you usually have bowel movements?
First thing in the morning
Later in the morning
In the afternoon
Immediately after meals
At night after dinner
Stools are usually
Soft
Medium
Hard
Variable consistency
Do you use enemas or laxatives? How often?
Do you have hemorrhoids? If yes, do they bleed?
Diet and Eating Behavior
Is your diet
Non-vegetarian
Mostly Vegetarian
Vegetarian
Which is your main meal?
Breakfast
Lunch
Dinner
Do you eat between meals?
Yes
No
How much time do you take for Breakfast, Lunch and Dinner?
Do you sit for 5-10 minutes after finishing a meal (circle one)?
Yes
No
Do you feel that you have an eating disorder now or in the past? If yes, please explain.
How often do you eat Leftovers?
Often
Sometimes
Rarely
Almost never
How often do you eat Frozen Foods?
Often
Sometimes
Rarely
Almost never
How often do you eat Packaged/processed foods?
Often
Sometimes
Rarely
Almost never
How often do you eat Cold foods and/or drinks?
Often
Sometimes
Rarely
Almost never
How often do you eat Raw vegetables (salad)?
Often
Sometimes
Rarely
Almost never
How often do you eat Red meat?
Often
Sometimes
Rarely
Almost never
How often do you eat spicy foods?
Often
Sometimes
Rarely
Almost never
How many times per week do you eat out in a restaurant or get takeout food?
How often do you microwave your food or drinks?
Often
Sometimes
Rarely
Almost never
About what percentage of your food is organically grown?
How many sodas, diet soda or seltzers do you drink each week?
What kind of water do you drink and what is the tempature (cold, hot, room temp) ?
Sleep
Is your sleep disturbed?
Not at all
Somewhat
Moderately
Severely
Very Severely
Do you take sleep aids
Yes
No
Are your bedtime and arising times consistent from day to day?
Very regular
Mostly regular
Somewhat regular
Mostly irregular
Daily Routine
How consistant is your daily routine (for example, do you go to bed, get up, and eat your meals around the same time daily)?
Very regular
Mostly regular
Somewhat regular
Mostly irregular
What time do you go to bed and rise in the morning (both weekdays and weekends)?
Do you generally eat your meals (breakfast, lunch, and dinner) at the same time every day?
Yes
No
How often do you exercise?
Regularly
Occasionally
Never
What type of exercise do you do, if any?
Is your exercise?
Vigorous
Moderate
Light
None
Do you practice yoga, breath, and meditation? How often? What kind(s)?
Do you take daytime naps?
Often
Sometimes
arely
Almost never
Do you travel a lot?
Yes
No
How often do you Smoke
How often do you Drink alcohol
Do you take enough time for yourself (why or why not)?
How many hours per day do you use a computer?
How many minutes per day on a cell phone
Are you having work or family problems that are impacting your health?
Yes
No
Are you having work or family problems that are impacting your health?
Yes
No
Do you perform “cleansings”? If so, describe.
How would you describe your mood?
Do you suffer from?
Anxiety
Depression
Anger
Mood swings
Are you currently in psychological counseling?
Yes
No
Menstrual History: Age of onset
Date of last period
Date of last GYN exam (please note any abnormalities
Do you take birth control pills and note length of time taking ?
Which of the following describes your menstruation? (Choose as many as apply)
Regular
Absent
Irregular
Too freqquent
Infrequent
Ceased due to menopause
Is your menstrual flow heavy, light or normal and how many days does it last?
Associated symptoms before or during menstruation, mention all that apply: none, fluid retention, pain, acne or other
Do you have any discharge outside of your menstrual period?
Yes
No
Do you have any itching of vaginal area?
Are you pregnant now?
Number of children
Number of pregnancies and describe any complications with pregnancy
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