Initial Health Consultation Intake Form

Initial Health Consultation Intake Form
Welcome.

Thank you for booking your Initial Ayurvedic Health Consultation.

Before your appointment, I kindly ask you to complete this Initial Consultation Intake Form. The information you provide will help me gain a comprehensive understanding of your health, lifestyle, daily routines, and current concerns, allowing me to prepare thoroughly for our consultation.

This intake form includes:

Personal Information
Health & Lifestyle Questionnaire
Prakriti (Constitution) Assessment
Vikriti (Current Imbalance) Assessment
Please answer all questions as accurately and honestly as possible. There are no right or wrong answers, and your responses will help ensure that any recommendations are tailored to your individual needs.

All information provided will be treated confidentially and used solely for the purpose of preparing for and conducting your Ayurvedic Health Consultation.

Thank you for taking the time to complete this form. I look forward to meeting you soon.

Warm regards,

Carol Das Neves
Ayurveda Health Consultant
Personal Details
Name

First NameLast Name
Date of Birth

DayMonthYear
Telephone

Area CodePhone Number
Occupation
Email
example@example.com
Height
Weight

Pakriti Assessment
This assessment is intended to gather information about your nature—the way you were as a child and the basic patterns that have been true for most of your life, not necessarily today. Think about your lifelong tendencies when answering these questions. Don’t worry if some of the descriptions don’t describe you exactly.

Instructions:

PLEASE READ CAREFULLY: Score a 5 for the description that most closely describes you, 1 for the one that least describes you, and 3 for the one that falls in the middle.

My natural frame can best be described as:

Rows	Score
Slight and narrow
Average, with good muscle tone
Sturdy and strong

My lifelong tendency with weight has been:

Rows	Score
I typically don’t gain weight easily, or I have trouble keeping it on
I can gain or lose weight easily, depending on what I focus on
I tend to gain weight easily and can have difficulty losing it

Most of my life, my body temperature has typically felt:

Rows	Score
Cold—my hands and feet are usually cold and I prefer warm environments
Warm—I am usually warm regardless of the season and prefer cool environments
Comfortable—I am adaptable to most temperatures

In general, my appetite is:

Rows	Score
Inconsistent—my hunger fluctuates and I tend to nibble, or sometimes forget to eat
Strong—I feel ravenous and can get irritable if I eat late; I don’t like to skip meals
Steady—I tend to feel full for a while after meals and can comfortably delay eating if I need to

Throughout my life, my stamina over the course of a day has been:

Rows	Score
Mild—I tend to start strong with lots of energy, but lose steam
Average—but I can push myself with a mind-over-matter attitude when needed
Enduring—I have great stamina but don’t typically like to test it

My lifelong tendency with sleep has been:

Rows	Score
I am a light sleeper and awaken easily
I sleep soundly for shorter periods of time than most people
I enjoy deep, long sleep

I prefer my daily routine to be:

Rows	Score
Flexible and spontaneous—I like to mix it up
Goal-oriented and challenging—I enjoy long, productive days
Predictable and steady—I’m good at keeping a routine and like structured days

Most of my life, I have most often made choices:

Rows	Score
Spur-of-the-moment—I often do things spontaneously based on my feelings and sometimes second-guess myself later
Precisely—I arrive at the best choice after researching options and am confident with my decisions
Slowly—I like to take my time making decisions or am fine with others making the decisions

For the majority of my life, my primary temperament has been:

Rows	Score
Enthusiastic—I enjoy trying new things
Purposeful—I am goal-oriented
Easygoing—I like to go with the flow

Usually, when under stress I become:

Rows	Score
Anxious and worried
Irritated and impatient
Withdrawn and unmotivated

Vikriti Assessment
This quiz is to assess your current state of balance of the doshas. Using the following scale, indicate how well each statement applies to your life experiences over the past 30-60 days.

Instructions

PLEASE READ CAREFULLY: Assign a score of 1 if the answer is Not at all, 3 if Somewhat/Occasionally and 5 if Very often. Then total each column.

Vata Mind

Rows	Not at all	Somewhat/ Occasionally	Very Often
I have been scattered and distracted
I have felt anxious or excessively worried
I have had difficulty staying asleep and wake with thoughts
My life has been chaotic and turbulent

Vata Body

Rows	Not at all	Somewhat/ Occasionally	Very Often
I have had more gas, bloating, or cramping after I eat
I have been constipated with hard, dry stools
I have been experiencing dry skin, dry eyes, or dry mouth
I have experienced muscle cramps, spasms, or twitches
I have been lightheaded or dizzy

Pitta Mind

Rows	Not at all	Somewhat/ Occasionally	Very Often
I have been obsessively focused on work, exercise, or other projects
I have felt irritable, frustrated, or impatient
I have had difficulty falling asleep or unwinding at the end of the day
I’ve been feeling overly critical or judgmental of myself or others

Pitta Body

Rows	Not at all	Somewhat/ Occasionally	Very Often
I have had acid reflux or acid indigestion
I have had loose stools or multiple stools per day
I have been experiencing red, itchy, or irritated skin
I have felt very hot or am experiencing hot flashes
I have been experiencing headaches

Kapha Mind

Rows	Not at all	Somewhat/ Occasionally	Very Often
I have been unmotivated and procrastinating
I have felt like withdrawing and not dealing with life
I have had difficulty waking up and feel groggy in the mornings
I have had difficulty leaving a relationship or job that no longer serves me

Kapha Body

Rows	Not at all	Somewhat/ Occasionally	Very Often
I have felt very full after eating, sometimes for an extended period of time
I have had sluggish elimination
I have had fluid retention in the tissues
I have had some weight gain or am above my ideal weight
I have had excessive congestion or mucus production

Scope of Practice

This consultation is based on the traditional principles of Ayurveda and provides personalised education and lifestyle recommendations to support health and wellbeing.

Recommendations may include guidance on nutrition, daily routines, sleep, stress management, meditation, breathwork, and other Ayurvedic lifestyle practices, taking into account your individual constitution and current state of balance.

Ayurveda is intended to work alongside conventional healthcare and is not a replacement for appropriate medical assessment or treatment when required.

If you have a medical condition, are experiencing new or worsening symptoms, or require diagnosis or treatment, you should seek advice from an appropriately qualified healthcare professional. Any changes to prescribed medication or medical treatment should always be discussed with your treating healthcare professional.
Client Declaration
Thank you for taking the time to complete this form. Your responses will help me prepare for our consultation and provide personalised Ayurvedic lifestyle recommendations.

I look forward to meeting you soon.

Warm regards,
Carol Das Neves
Should be Empty:

Rows	Low	Moderate	High
Morning
Afternoon
Evening

Initial Health Consultation Intake Form

Personal Details

Health & Lifestyle Questionnaire

Medical History

Current Medication & Supplements

Family Medical History

Digestion

Sleep

Energy

Stress & Emotional Well-Being

Daily Lifestyle

Women's Health (if applicable)

Your Health Goals

Additional Information

Pakriti Assessment

Vikriti Assessment