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Ayurvedic Intake

There are 47 questions in this survey.
Basic Info
First, Middle, Last Name
Sex
Marital Status
Age/Weight

Height

For example 5 feet 5 inches is 5.5

Date of Birth
Time of Birth
Enter in exact time you were born example: 12:21pm
Place of Birth/Occupation/Email/Living Situation/Referred by
Home Address
Emergency Contact
What is your ethnicity?
Conditions - History
What do you hope to achieve with your health consultation today?
Main problem(s) you would like help with
Mild – Some discomfort
Moderate – Creates much trouble, but can continue regular activities
Severe – Restricts your daily routine 
  Describe problem Start date Mild/Moderate/Severe Attempted treatment and response
Problem 1
Problem 2
Problem 3
Problem 4
Are you diagnosed with any medical conditions?
  Condition Start date Control status Treating physician, affiliation
Condition 1
Condition 2
Condition 3
Are you taking any prescription medications?
  Name Start date Dosage Prescribed by
Medication 1
Medication 2
Medication 3
Are you taking any herbal or alternative medicine?
  Name Start date Dosage Prescribed by
Herbal/alternative medicine 1
Herbal/alternative medicine 2
Herbal/alternative medicine 3
Are you taking any vitamins or nutritional supplements?
  Name with dose of main ingredients Start date Regularity Given by
Vitamin or nutritional supplement 1
Vitamin or nutritional supplement 2
Vitamin or nutritional supplement 3
Family History

Type "x" in any boxes for family member that had specified disease

"Other" box list any other diseases not included

For cause of death please type in disease

PGM, PGF = Paternal Grandmother, Grandfather
MGM, MGF = Maternal Grandmother, Grandfather
  Father Mother Brother Sister PGM PGF MGM MGF
Diabetes
Hypertension
Heart Disease
Stroke
Asthma
Cancer (type)
Hypo/Hyperthyroid
Arthritis
Other
If not living, age of and cause of death
Were there any diseases that you suffered from earlier?
Include major infections like typhoid, malaria, hepatitis
  Disease Start and end date Treatment – drugs, exercise, etc.
Disease 1
Disease 2
Disease 3
Have you had any kind of surgery or minor procedures performed on you?
Include any Panchakarma, Acupuncture and other treatments here as well
  Procedure Date Who and where was it performed
Procedure 1
Procedure 2
Procedure 3

Please list any hospitalizations

  Condition Year Procedure done
Hospitalization 1
Hospitalization 2
Hospitalization 3
Conditions - Current

How much do you physically move your body?

  Activity Intensity Hours Days/ week Start date
Activity 1
Activity 2
Activity 3
Sweat/TV
Typically while eating food...
Never Sometimes Most of the time All the time No answer
While eating do you watch TV?
While eating do you Read Books?
While eating do you Browse/Surf Phone/Tablet?
Do you connect with yourself? How and how often?
Hobbies/music/ meditation/ community service etc.
Stress/Energy
1 - Low (Not at all)
5 - Moderate
10 - High (Extreme)
Level
How stressed you have been?
What is your energy level?
Overall how hungry do you feel at different meal times?
How hungry do you feel at different meal times?
Time - 11am, 2pm, 2:30pm, etc
How Hungry - 1 – not at all, 2-3 – mildly hungry, 4-7 moderately hungry, 8-9 – quite hungry, 10 – very hungry! 
  Time How Hungry (1-10) What food or drink typically
Breakfast
Mid-morning
Lunch
Snack
Evening
Dinner
Bedtime
Rate on a scale of 1-5 how the following applies
1= Always, 2= Often, 3=Sometimes, 4=Rarely, 5=Never
Scale of 1-5
Is the above pattern (Hunger at meal times) mentioned irregular?
Can you skip meals easily?
Are you mostly always ready to eat – whatever the time of the day it is?
If hunger is not gratified, do you feel uncomfortable or irritable?
Do you end up feeling fuller earlier than expected at the start of a meal?
Are there times when even little quantity of food doesn’t get digested for a long time?
Does your food get digested well on some days and sometimes not?
Drinking/Smoking Habits
Heavy Moderate Light None
Alcohol
Coffee
Tea
Tobacco
Marijuana
Other
Weather Preference
Hot Cold Both Neither
Which weather do you prefer?
Which extreme of weather are you unable to tolerate?
Which taste do you prefer?
Astringent = Apples, bananas (green), cranberries, pomegranate, Popcorn, Alfalfa sprouts, avocado, broccoli, brussels
Other:
Thirst/Sweat
Often Moderate Not much
How thirsty do you feel typically?
Do you sweat easily?
Symptoms
Please indicate below any symptoms you have experienced in the last three months:
General Symptoms
Other:
Skin and Hair
Other:
Head
Other:
Eyes, Ears, Nose and Throat
Other:
Cardiovascular
Other:
Respiratory
Other:
Musculoskeletal
Other:
Gastrointestinal
Other:
Genito – Urinary
Other:
Neuropsychological
Other:
Pregnancy and Gynecology
Other:
Pregnancy and Gynecology continued
Consent

HIPAA Notice Of Privacy Practices

We keep medical records of the health care services we provide for you.  You may ask to see and copy your records. You may ask to correct your records.  Your records will be kept confidential unless you give us written permission to release them or we are required to do so by law.

We will ask you to sign a consent form allowing us to use and disclose your health information for purposes of consultations, payment and health technique operations in this office.  You may see your records or get more information about them by contacting our office. 

For more information about our privacy practices please inquire with us. By signing below, I acknowledge receipt of the Notice of Privacy Practices. 

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Type your name in the text box as your signature

Welcome to Dosha Ayurveda. As you know, we are practitioners of Ayurveda. We are not licensed physicians, nor are Ayurveda services licensed by the state. Ayurveda is the 5000-year-old Wisdom of Healthy living. It is a way of natural healing and emphasizes on maintaining the harmony of Body-Mind-Spirit through diet, lifestyle, and natural herbs. In Ayurveda the emphasis is not on a disease but on maintaining the balance of individual Body Constitution, so Ayurvedic treatments are never one size fits all, but they are custom tailored for each individual need. We provide you with the following kinds of services:

  Body- Constitutional Analysis 
  Diet and the Lifestyle Counseling 
  Ayurvedic Body Techniques 
  Yoga and Meditation Practices 

Our method of treatment in Ayurveda is alternative or complementary to conventional medicine. If you ever have any concerns of your Ayurvedic practices, please feel free to discuss them with us. We recommend that you inform your medical doctor that you are receiving Ayurvedic advice. I have read and understood the above disclosure about the Ayurvedic services offered by practitioners of Dosha Ayurveda. I have disclosed with them the nature of the services to be provided. I understand that the practitioners are not licensed physicians and the Ayurvedic services are not licensed by the state. I understand it is my responsibility to maintain a relationship for myself with a medical doctor.

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Missed Appointment Policy

Please give us at least 48 hours cancellation notice for an initial appointment, and 24 hours’ notice for the follow up appointment. This allows us to call those waiting for an appointment to take your place. 

Please also be aware that the wellness allots a specific amount of time for each treatment and that if you arrive late, the length of your treatment will be adjusted to fit that schedule.

I have read and agreed to the missed appointment policy.

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