Initial Intake Forms

Welcome to The Ojas Clinic

No fields are required- please only share with us what you want us to know and are comfortable with providing. This form is HIPPA compliant- all information you provide will remain confidential.
Name
Date

MonthDayYear
Date
Email address
example@example.com
Telephone (mobile)
Birth date

MonthDayYear
Date
Occupation
What would you describe as being your primary goals for your overall health and wellness?
Do you have any current health concerns, diagnoses, or problems?
Have you undergone any significant surgeries or treatments?
Please list any medications you are currently using including prescriptions, birth control pills, hormone replacement therapy, vitamins, or other supplements
Are you allergic to or intolerant of any foods, herbs, spices, or medications?
Daily Routine

Help us understand what a typical day looks like for you.
How would you describe your daily routine?

Very regularSomewhat regularVaries from day to day
How often do you exercise?

Daily3-5 x per week1-2 x per weekLess than 1x per week
What types of exercise do you engage in?
What time do you usually wake up?
What time do you usually go to bed?
Do you experience any of the following? (select all that apply)

Difficulty falling asleepTrouble staying asleepFrequent wake upsNight sweats
Do you use sleep aids or sedatives?

YesNoSometimes
How many hours per day do you use a computer, laptop, or cell phone?
Diet

Include brief examples of what you might eat for each meal and at what time of day;
Breakfast
Lunch
Dinner
Snacks
List any special dietary needs;
Are there any foods that cause discomfort?
Do you tend to feel heavy or fatigued after eating?

YesNoVaries
What is your largest meal of the day?

BreakfastLunchDinnerVaries
How would you describe your digestion?

GoodFairPoor
Do you experinece any of the following (check all that apply);

BloatingConstipationAcid refluxIndigestion
How would you describe your appetite?

StrongRegularWeakVaries
What kind of water do you drink regularly (filtered, tap, bottled, etc.)?
How many caffeinated beverages do you consume daily?
Physical Balance

Rate the following statements based on how accurately you feel they apply to you;
I do not feel energized and well rested upon waking up

1

2

3

4

5

1 is Disagree, 5 is Agree
I tend to feel like something is not functioning properly in my body

1

2

3

4

5

1 is Disagree, 5 is Agree
I feel like there are obstructions and blockages in my body (sinuses, digestive system, etc.)

1

2

3

4

5

1 is Disagree, 5 is Agree
I feel like I succumb to illness easily or frequently

1

2

3

4

5

1 is Disagree, 5 is Agree
Check any symptoms that you experience;

Seasonal allergiesChronic fatigueJoint painInflammationBrain fogCold hands/ feetSwellingRashes, skin irritation, or rednessTinnitusDry skinBrittle hair/ nailsHeart palpitationsSinus congestionLow back painDizzinessOther
Hormonal Balance
Menstruation (if applicable);

MenstruatingPerimenopausalMenopasualPost-menopausal
Have you experienced any of the following in relation to menstruation/ menopause? (check all that apply)

Severe cramping (dysmenorrhea)Migraine headachesHeavy flow (menorrhagia)Hot flashesPMDD (premenstrual dysphoric disorder)Mood swingsBloatingDrynessHormonal acneFrequent UTIWeight gainOther
Do you use a form of contracpetion?

NoYes
If yes, describe the type
Length of time taking
Mental Balance
Do you experience any of the following? (select all that apply)

AnxietyPanic attacksDepressionMood swingsIntense anger or frustration
How would you describe your mood?

I generally feel happy, content, and presentMy mood varies from day to dayI tend to feel unhappy, not present, and discontentedOther
Choose a location;
Should be Empty:

Welcome to The Ojas Clinic

Daily Routine

Diet

Physical Balance

Hormonal Balance

Mental Balance