Form

First Time Evaluation
Today's Date

- Month - Day Year
Referred By:
Name

First Name Middle Name Last Name
E-mail
Contact Number:

- Area Code Phone Number
Date of Birth

Month Day Year
Height (inches)
Weight (pounds)
Marital Status
Number of Children

Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

1. Complaints
Please rank your current complaints and rate their severity (on a scale of 1 to 10, 10 being the most severe)
2. Please tell us any additional information or concerns about your health
3. Medications
Please list any medications you are currently taking and how long you have taken them (including birth control pills, aspirin, pain medications, etc.)
4. Smoking
Do you currently smoke?

Yes No
If yes, how much?
If yes, how long have you smoked?
5. Surgeries
What surgeries, operations, traumas, car accidents, etc. have you had?
a.) Have you ever had full-body anesthesia (i.e. to remove tonsils, widom teeth, etc.)?

Yes No
b.) Do you have breast implants?

Yes No
Other surgical implants or prostheses?
6. Stress
Please rate your current stress level (on a scale of 1 to 10, 10 being the highest stress):
What is the main reason(s) for your stress?
If over level 5, what step(s) are you taking to reduce your stress level?
7. Dental work
Indicate how many of the following you have:
Indicate how many of the following you have:

Silver fillings Root canals Braces Bleeding Gums Extractions Posts Sensitive teeth Bridgework Implants Bad Bite Partial or full dentures Veneers Temporaries Porcelain crowns or inlays DeGussa Porcelain crowns or inlays Gold crowns or inlays
Have you had any teeth extracted (widsom teeth, four bicuspid extraction etc.)?
Do you need further dental work? If so, what?
Health Overview

For the following questions, check the phrases that apply to you.
1. Sleep
How is your sleep?

restful restless hard to sleep wake up often get up during the night bad dreams
Any complaints?
What time do you usually go to sleep?
Number of hours of sleep per night?
2. Digestion
How is your digestion?

poor acid reflux burp often bloating burning or pain in stomach
Any complaints?
3. Urination
How are your daily urinations?

Every 2 to 3 hours Too frequent Sense of urgency Too little amount Too large amount Burning Dribbling Up at night several times
Any complaints?
4. Bowels
How are your bowel eliminations? How Often?

Once per day 2 times daily 3 times daily Skip days Amount: normal Amount: too little Amount: too large Consistency: normal Lots of mucus Too hard Very soft Diarrhea Lots of gas Foul smell Color: brown Color: black Color: whitish
6. Exercise
What kind of exercise do you do?
How often?
5. Women Only
Are you pregnant?

Yes No
Are you breast-feeding?

Yes No
Do you have monthly periods?

Yes No
Date of last menstrual period?

- Month - Day Year
Are you going through menopause?

Yes No
Have your periods stopped?

Yes No
Have you had a hysterectomy?

Yes No
(If so, when?)

- Month - Day Year
Menstrual Cycle
Are your monthly periods regular (28 day cycles)?

Yes No
Number of days of your menstrual flow?
Do you experience any of the following symptoms associated with your period?

cramping bloating feeling weak mood swings cravings heavy bleeding back pain headaches bright red blood dark clotty blood.
Any menstrual complaints?
Y.M.I. is a 501-c-3, non-profit, educational organization dedicated to teaching and spreading the wisdom of natural healing.

Disclaimer: These statements have not been evaluated by the Food and Drug Administration. None of this information is meant to diagnose, treat, cure or prevent any medical conditions or disease. Ayurveda is a spiritual tradition of wellness and longevity meant to educate about foods, including herbs and supplements, and about meditation. This information is not meant to replace or in any way substitute for medical advice. For medical advice consult a licensed medical physician.
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First Time Evaluation