Ayurvedic Wellness & Subtle Body Consultation Intake

Please complete this intake form before your consultation.

All fields are optional except for signature and date.
Mandatory Disclosure & Informed Consent

Jennifer Misterka is an Advanced Yoga Specialist, Master Life Coach, and Ayurvedic Wellness Practitioner. She is not a licensed medical professional. In the state of Maryland, her services and the services of Luminous Path Yoga & Wellness are considered complementary and alternative wellness services. At Luminous Path Yoga & Wellness we do not diagnose, treat, or cure any medical or mental health conditions. This consultation is educational and supportive, utilizing various Ayurvedic lineages including Shaka Vansiya Ayurveda (SVA), Sound Healing, Reiki, and Marma Therapy. These services do not replace the care of a licensed medical professional.
Personal Information
Full Name

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Email Address
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Phone Number
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Address

Street Address

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Current Age
Date of Birth

MonthDayYear
Date
Gender Identity
Occupation (Health & Wellness Professionals receive 50% off ONE Private Session per Quarter)
Consultation Details
Referral Source (How did you hear about us?)
Pregnancy Status: Are you currently pregnant or nursing?
Dietary Quality: Do you primarily eat freshly cooked, warm, organic meals?
The Nightshade Check: How often do you consume potatoes, tomatoes, eggplant, or bell peppers?
Leftovers: How often do you eat food that has been refrigerated and reheated?
Water Temperature: What is your preferred temperature for drinking water?
Post-Meal Sensations
Tongue Observation: When you look at your tongue in the morning, do you notice a coating?
Elimination: Do you have a bowel movement every morning upon waking?
Average Bedtime

Hour Minutes

AM/PM Option
Average Wake-Up Time

Hour Minutes

AM/PM Option
Sleep Continuity: Do you have trouble staying asleep through the night?
Sleep Quality & Challenges: If you experience fitful sleep, waking (e.g., between 2:00 AM – 4:00 AM), or difficulty falling asleep, please describe
Waking Energy: Upon waking, do you feel rested, or do you feel heavy, stiff, or "foggy"?
Medical Devices & Implants: Do you have any of the following?
Sound Sensitivity: Do you have extreme sensitivity to sounds or specific frequencies?
Comfort with Touch: For Marma and Reiki work, are you comfortable with light, therapeutic hands-on touch?
Topical Sensitivities: Do you have any skin allergies or sensitivities to essential oils?
General Allergies: Please list all food or seasonal allergies
Current Medications: Please list any prescriptions you are currently taking (This is for safety screening to ensure compatibility with Ayurvedic routine)
Supplements & Herbs: List any vitamins or botanicals you take regularly
Medical History: Have you had any surgeries or major illnesses in the last year?
EMF Exposure: How many hours a day are you in close proximity to a computer, smartphone, or Wi-Fi router?
Chemical Exposure: Do you use synthetic perfumes, air fresheners, or commercial detergents?
Stress Level: On a scale of 1–10, how would you rate your current stress?

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
Emotional Tendency: When under pressure, do you tend toward:

Other (please explain)
Other Option: Please explain.
Current Movement: What is your regular physical movement entail? (Examples: Yoga, Barre, Hiking, Swimming, etc.)
How often are you active?
Please list your main health concerns & primary wellness goals for our work together.
Please describe your current diet.
What time of the day do you usually eat you meals?
Do you have any chronic health conditions?
Are you familiar with energy work, meditation, or other subtle body practices?
If you answered "yes" to the above question, are you currently engaged in any of these practices on a regular basis?
Is there anything else you would like to share before your session?
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Please complete this intake form before your consultation.

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