Re Nu Wellness Center Client Intake Form

Re Nu Wellness Center Client Intake Form

New client intake for an Ayurvedic wellness center. Please complete all questions based on the source document.
Client Details
Date Of Initial Appointment

MonthDayYear
Date
Name
Address
City, State & Zip
Telephone: Home
Please enter a valid phone number.Format: (000) 000-0000.
Telephone: Cell
Please enter a valid phone number.Format: (000) 000-0000.
Telephone: Other
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Birth Date

MonthDayYear
Date
Age
Occupation
Weekly Hours Spent Working
Marital Status
Number of Children & Ages
Consultation Background
Reason for Ayurvedic Consultation
Past Medical History - Operations / Major Conditions
Under Care of Licensed Professional in Past Year
If Yes, Reasons for Care
Family History
High Blood Pressure
Heart Disease
Diabetes
Cancer
Mental Disorder
Stroke
Other
Substance Use and Practitioner Notes
Alcohol Use Frequency/Type

Other
Tobacco Use

Other
Addictive Substances
Practitioner Notes
Lifestyle and Habits
Exercise

Other
Spiritual practices

Other
Hobbies
Daily liquid intake (cups/glasses)
Eating patterns
Allergies
Meals most often

Other
Daily routine and habits
Daily Schedule
Daily schedule entries
Wake-up Time

Hour Minutes

AM/PM Option
Bedtime

Hour Minutes

AM/PM Option
Breakfast Time

Hour Minutes

AM/PM Option
Lunch Time

Hour Minutes

AM/PM Option
Dinner Time

Hour Minutes

AM/PM Option
Exercise Time

Hour Minutes

AM/PM Option
Additional schedule details
Current Medications, Herbs, and Supplements
Current Medications, Herbs, and Supplements
Prakruti Assessment
Body Frame
Body Build
Muscle Development
Skin Quality
Hair Type
Eyes
Appetite
Thirst
Sleep Pattern
Speech
Memory
Walking Style
Temperament
Vikruti Symptom Checklist
Digestive symptoms
Digestive symptoms details

Other
Digestive symptoms notes
Bowel habits
Bowel habits details

Other
Bowel habits notes
Sleep symptoms
Sleep symptoms details

Other
Sleep symptoms notes
Energy and fatigue
Energy and fatigue details

Other
Energy and fatigue notes
Mood and mental state
Mood and mental state details

Other
Mood and mental state notes
Head and senses
Head and senses details

Other
Head and senses notes
Skin and hair
Skin and hair details

Other
Skin and hair notes
Musculoskeletal symptoms
Musculoskeletal symptoms details

Other
Musculoskeletal symptoms notes
Circulation and temperature
Circulation and temperature details

Other
Circulation and temperature notes
Respiratory symptoms
Respiratory symptoms details

Other
Respiratory symptoms notes
Reproductive and urinary symptoms
Reproductive and urinary symptoms details

Other
Reproductive and urinary symptoms notes
Psychosocial and Additional Concerns
Employment status
Describe your work or school stressors
Work-life balance
Relationship status
Describe your relationships and support system
Spiritual or religious affiliation
Any spiritual or existential concerns
Average hours of sleep per night
Sleep quality
Average energy level on a 0-10 scale
Sleep-related concerns

Other
Current psychosocial concerns

Other
Describe any additional concerns
How ready do you feel to make lifestyle changes
Anything else you would like to share
Should be Empty:

Re Nu Wellness Center Client Intake Form

Client Details

Consultation Background

Family History

Substance Use and Practitioner Notes

Lifestyle and Habits

Daily Schedule

Current Medications, Herbs, and Supplements

Prakruti Assessment

Vikruti Symptom Checklist

Psychosocial and Additional Concerns