Ayurvedic Intake FormPlease fill this out minimum 24 hours prior to your appointment. Thank you! Name * First Name Last Name Email * Birth gender, preferred gender pronoun * Current location * What is your goal for this cleanse in 1 word? * Age + birthdate (include time+ location if known) * Profession * Goal for this Consultation * Current health concerns, medical diagnosis * Previous health concerns / Injuries / Illnesses with dates * Family Health History * Describe your sleep (check all that apply) * Light Medium with vivid dreams Deep Have trouble falling asleep Have trouble staying asleep Wake up to pee in the night Irregular How many hours do you usually sleep per night? Which hours are they? Describe your meals: What and when do you eat breakfast, lunch, dinner? Describe your eating habits (check all that apply) Hungry often Irregular appetite Slow to get appetite in the morning Tend to skip meals Eat only when hungry Eat often when not hungry How many times do you eat out per week? Do you have any food allergies? Are you vegetarian or vegan? Urination and Defecation Pee a lot Pee a little Pee a normal amount Poop 1x per day Poop 2x per day Poop 2+ times per day Tend toward constipation Tend toward diarrhea Tends towards alternating constipation/diarrhea Women's Health: Describe your menstratuion cycle. Is it regular, how long, how heavy? Do you have children, if so what ages? Physical Body. Do you tend to: Run hot in body temperature Run cold in body temperature Have cold hands or feet Dry skin Oily skin Red/ sensitive skin Sunburn easily Have dry hair Have oily hair Tend to acne or rashes Get hives Describe emotions you feel when you are in balance? Out of balance? Explain your spiritual or physical practices (including meditation, yoga, or physical exercise). What are your practices and how often? Caffeine consumption: Do you drink caffeine regularly? Coffee or tea? How often, what times and how much, black or with milk? Do you consume alcohol? How much, how often and types? Do you smoke tobacco, marjiuana, or use recreational drugs? How much and how often? How is your energy most days? Are you currently taking any prescription medication (including birth control) or herbal supplements? If so, what dosage and when? Any additional information you would like to add? Thank you!
