Dr. Pratima Raichur

Ayurvedic Consultation Intake Form

To better understand your health needs, please carefully complete this intake form. All information is stored securely and is strictly confidential.
CONTACT INFORMTION
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
Phone Number*
Emergency Contact*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.
How did you hear about us?*
PERSONAL INFORMTION
Biological Sex*
Gender Indentity
Age*
Height*
Date of Birth*

MonthDayYear
Date
Weight (lb.)*
Eye Color
Natural Hair Color
Marital Status
Children*
How many children do you have?
HEALTH HISTORY
Please check if you are:

PregnantBreastfeedingMenopausalUsing hormonal birth controlPerimenopausalTrying to become pregnant
If you menstruate, is your flow regular?
Please indicate your typical flow:
During menstruation, do you experience:

Pain / CrampsPMSBreast tendernessClotting
Last menstrual period

MonthDayYear
Date
Length (in days) of typical period and between cycles
e.g. if period lasts 7 days and occurs every 28 days, write 7/28
Exercise Activity*

ModerateVigorousSeldom
Exercise days/week:
Please check any applicable dietary preferences below:

VegetarianVeganOmnivorePaleo / KetogenicGluten-free
Describe your diet:
Nicotine Use*

NoDailyWeeklyLessFormer Use
Caffeine Use*

NoDailyWeeklyLessFormer Use
Alcohol use*

NoDailyWeeklyLessFormer Use
Cannabis Use*

NoDailyWeeklyLessFormer Use
CBD Use*

NoDailyWeeklyLessFormer Use
Please list any supplements or medications you are taking:*
If none, please type N/A
Please list any known allergies and the allergic reactions:*
e.g. Pets/respiratory; peanuts/anaphylactic, etc. If none, please type N/A.
Please list any medically diagnosed illnesses or health conditions:*
If none, please type N/A.
SKIN

Please check any symptoms you are currently experiencing.
Vata

Skin drynessFine linesEczema (dry)Psoriasis or Scaly SkinCracked Hands and/or FeetDandruff
Pitta

Combination skinAcneEczema (burning or itching)RosaceaRashesBroken CapillariesItchy or irritated scalp
Kapha

Skin CongestionBlackheadsEczema (moist or sticky)Cystic AcneDeep WrinklesOily Scalp
DIGESTION

Please check any symptoms you are currently experiencing.
Vata

Low AppetiteSudden Weight LossGasBloatingConstipation
Pitta

ConstipationHeartburnNauseaUlcersAcid refluxLoose stoolDiarrheaNotable weight fluctuations
Kapha

Stubborn weight gain / retentionSluggish metabolismDiabetesFrequent urinationPost meal fatigue
PHYSIOLOGICAL

Please check any symptoms you are currently experiencing.
Vata

Cold extremitiesArthritisDry coughJoint painOsteoporosisLower back pain
Pitta

Excessive Heat/PerspirationMigrainesExcessive ThirstBurning, Sharp Pain
Kapha

Difficulty SweatingRespiratory Issues/AsthmaCold, Clammy HandsDull, Vague Pain
NEUROLOGICAL

Please check any symptoms you are currently experiencing.
Vata

InsomniaRestlessnessAnxiety/FearDifficulty Focusing
Pitta

Interrupted SleepMigrainesFeeling Out of ControlAnger/RageEnvy
Kapha

Lethargy or FatigueDepressionGreedBrain FogAttachment
YOUR UPCOMING CONSULTATION
Please share the main topics you would like to discuss.
Select relevant categories for your consultation:

Fertility / Conception / Pre or PostnatalNutrition / Diet / Digestion / Weight ManagementSkin, Scalp, Hair, or Nail HealthEnergy / Mood / Mental HealthLifestyle and Daily RhythmAge SupportHormone Balance / Endocrine HealthVision and Hearing
In Ayurveda, ama is defined as undigested food, thoughts, or emotions. Select all applicable symptoms of ama you are currently experiencing:

Feeling weak, heavy and sluggishIndigestion, acid reflux, burpingExcessive salivation, coating on tongueGas, bloating and constipationLack of taste and smellCloudy thinking, memory lossObstruction of bodily process (swelling, pain, inflammation)Fluid retentionUrine: cloudy, burning, difficultFrequent throat clearing
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CONSENT
Consent and Liability Release I certify that the information given above is accurate and complete to the best of my knowledge and that I have communicated all of my known medical conditions. I understand that I am responsible for my own participation in any given treatment and/or program. I hereby release Dr. Pratima Raichur, Pratima Ayurvedic Skincare Spa Clinic and any designated individual from any legal or financial responsibility with respect to my or mychild’s participation in any given treatment or program.

Cancellation Policy We request 24 hours notice when canceling an appointment. Late cancellations and no-shows will be charged in full to your credit card on file. Full payment is expected at the time of service. These services are non-refundable.
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Date*

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Ayurvedic Consultation Intake Form

CONTACT INFORMTION

PERSONAL INFORMTION

HEALTH HISTORY

SKIN

DIGESTION

PHYSIOLOGICAL

NEUROLOGICAL

YOUR UPCOMING CONSULTATION

CONSENT