Initial Intake Forms

Welcome to The Ojas Clinic

Please share only what you feel comfortable disclosing- all information is protected and confidential under HIPAA compliance.
Name
Date

MonthDayYear
Date
Email address
example@example.com
Telephone (mobile)
Format: (000) 000-0000.
Birth date

MonthDayYear
Date
Occupation
Please describe your primary health concerns and overall goals for your health and wellness;
Please describe any current or past medical conditions, diagnoses, or symptoms;
Have you undergone any surgeries, hospitalizations, or major medical treatments? If so, please provide details and approximate dates;
Please list all current medications, including prescription drugs, over-the-counter medications, hormonal therapies, vitamins, or supplements;
Do you have any known allergies or intolerances to foods, medications, herbs, or environmental substances? If so, please list them below;
Daily Routine

Help us understand what a typical day looks like for you.
Breifly describe your daily routine;
Include work hours, typical daily activities, and any wakeup / wind down routines
Is your routine regular from day to day?
How often do you exercise?
What types of exercise do you engage in?
What time do you typically wake up and go to sleep?
Do your wake / sleep times tend to be regular from day to day?
Do you experience any of the following? (select all that apply)
Do you use sleep aids or sedatives?
How many hours per day do you spend using a computer, phone, or other electronic devices?
Diet

Include brief examples of what you might eat for each meal and at what time of day;
Breakfast
Lunch
Dinner
Snacks
Are your mealtimes regular from day to day?
What is your largest meal of the day?
List any special dietary needs;
Are there any foods that cause discomfort?
What type of water do you drink regularly (filtered, tap, bottled, spring)?
How many caffeinated beverages do you consume daily?
Digestion & Elimination
Do you tend to feel heavy, fatigued, or lethargic after eating?
Do you experinece any of the following (check all that apply);
How would you describe your appetite?
Do you experience any urgency, increased frequency, pain, or burning with urination?
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
I tend to feel tired or exhausted regardless of physical exertion.

1

2

3

4

5

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

Other
Hormonal Balance
Women
Menstruation (if applicable);
Have you experienced any of the following in relation to menstruation/ menopause? (check all that apply)

Other
Do you use a form of contracpetion?
If yes, specify type and duration of use;
Men
Have you expereinced any significant changes in libido?
Have you noticed changes in hair/ body hair, muscle mass, or energy levels?
Do you expereince any pain, swelling, or tenderness in the groin?
Mental & Emotional Balance
Do you experience any of the following? (select all that apply)
How would you describe your mood?

Other
How would you describe your energy levels throughout the day?
To what extent do you feel stress is affecting your overall health and well-being?
Should be Empty:

Welcome to The Ojas Clinic

Daily Routine

Diet

Digestion & Elimination

Physical Balance

Hormonal Balance

Women

Men

Mental & Emotional Balance