Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

How do you get to work?

Work at home

Walk

Drive

Public Transport

Other

Do you have children?

Yes

No

How would you qualify your knowledge of Ayurveda?

Not much

Basics

Extensive study

Other

Grandmother (maternal) Family History

please include age, profession, health history, (died of)

Light

Medium with vivid dreams

Deep

Have trouble falling asleep

Have trouble staying asleep

Wake up to pee in the night

Name *

First Name

Last Name

Name *

First Name

Last Name

For those who bleed, please check any that apply:

flow contains clots

flow contains membranes

cramps

pms symptoms

Name *

First Name

Last Name

Do you fall asleep right away?

Yes

No

How do you sleep?

Side

Back

Belly

Do you move a lot in the night?

Yes

No

Do you feel rested in the am?

Yes

No

Is your energy stable throughout the day?

Yes

No

What is your mood?

Up

Down

Variable

Calm

Angry

Happy

Sad

Worried

What is your stress level?

High

Medium

Low

Name *

First Name

Last Name

Check any digestive symptoms you experience:

Bloating

Gas

Burping

Belching

Acidity

Heartburn

Other

Name *

First Name

Last Name

Please check any that apply:

stool floats

stool sinks

Gas upon sitting

mucus in stool

blood in stool

burning

straining

undigested food in stool