Welcome to The Ojas Clinic
Please share only what you feel comfortable disclosing- all information is protected and confidential under HIPAA compliance.
Name
Date
/
Month
/
Day
Year
Date
Email address
example@example.com
Telephone (mobile)
Birth date
/
Month
/
Day
Year
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?
Very regular
Somewhat regular
Varies from day to day
How often do you exercise?
Daily
3-5 x per week
1-2 x per week
Less than 1x per week
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?
Very regular
Somewhat regular
Irregular
Do you experience any of the following? (select all that apply)
Difficulty falling asleep
Trouble staying asleep
Frequent wake ups
Night sweats
Do you use sleep aids or sedatives?
Yes
No
Sometimes
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?
Very regular
Somewhat regular
Irregular
What is your largest meal of the day?
Breakfast
Lunch
Dinner
Varies
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?
Yes
No
Varies
Do you experinece any of the following (check all that apply);
Constipation
Indigestion
Loose Stools
Gas / Bloating
Heartburn / Acid Reflux
Straining / Difficulty Eliminating
How would you describe your appetite?
Strong
Moderate
Low
Varies
Do you experience any urgency, increased frequency, pain, or burning with urination?
Yes
No
Sometimes
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.
Disagree
1
2
3
4
Agree
5
1 is Disagree, 5 is Agree
I tend to feel like something is not functioning properly in my body.
Disagree
1
2
3
4
Agree
5
1 is Disagree, 5 is Agree
I feel like there are obstructions and blockages in my body (sinuses, digestive system, etc.).
Disagree
1
2
3
4
Agree
5
1 is Disagree, 5 is Agree
I feel like I succumb to illness easily or frequently.
Disagree
1
2
3
4
Agree
5
1 is Disagree, 5 is Agree
I tend to feel tired or exhausted regardless of physical exertion.
Disagree
1
2
3
4
Agree
5
1 is Disagree, 5 is Agree
Check any symptoms that you experience;
Seasonal allergies
Chronic fatigue
Joint pain
Inflammation
Brain fog
Cold hands/ feet
Swelling
Rashes, skin irritation, or redness
Tinnitus
Dry skin
Brittle hair/ nails
Heart palpitations
Sinus congestion
Low back pain
Dizziness
Issues with memory / recall
Other
Hormonal Balance
Women
Menstruation (if applicable);
Menstruating
Perimenopausal
Menopasual
Post-menopausal
Have you experienced any of the following in relation to menstruation/ menopause? (check all that apply)
Severe cramping (dysmenorrhea)
Migraine headaches
Heavy flow (menorrhagia)
Hot flashes
PMDD (premenstrual dysphoric disorder)
Mood swings
Bloating
Dryness
Hormonal acne
Frequent UTI
Weight gain
Other
Do you use a form of contracpetion?
No
Yes
If yes, specify type and duration of use;
Men
Have you expereinced any significant changes in libido?
Yes
No
Have you noticed changes in hair/ body hair, muscle mass, or energy levels?
Yes
No
Do you expereince any pain, swelling, or tenderness in the groin?
Yes
No
Mental & Emotional Balance
Do you experience any of the following? (select all that apply)
Anxiety
Panic attacks
Depression
Mood swings
Intense anger or frustration
Overwhelm
Irritability
Restlessness
Difficulty Focusing
How would you describe your mood?
I generally feel happy, content, and present
My mood varies from day to day
I tend to feel unhappy, not present, and discontented
Other
How would you describe your energy levels throughout the day?
Consistent
Fluctuating / Inconsistent
Low
High
To what extent do you feel stress is affecting your overall health and well-being?
Not at all
Mildly
Moderately
Significantly
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