Ayurveda Initial Assessment

First name

Last name

Phone

Age

Address

Occupation

Gender

Female

Male

Other

Height

Weight

Any weight gain or loss in the past 6 months?

Are you allergic to, or intolerant of, any HERBS, SPICES, FOOD, or DRUGS?

What are your goals for your wellness consultation today?

Do you have any current health concerns or problems?

Any significant previous health concerns or problems?

Any significant family history of health problems?

Please list all prescription medications, birth control pills, hormone replacement therapy, vitamins or other supplements that you are taking:

Please list foods and drinks you typically eat for breakfast:

Please list food and drinks you typically eat for lunch:

Please list food and drinks you typically eat for dinner:

Please list food and drinks you typically eat for snacks:

Any special dietary needs?

Previous Ayurvedic evaluations and treatments:

Is your digestion:

Good: regular bowel movements, no discomfort or bloating after meals, good appetite, ability to digest a variety of foods without adverse reactions, feeling energized and light after meals, occasional gas or mild bloating (easily relieved)

Fair: bowel movements may be irregular (every other day), stools may vary in consistency but are generally manageable, some occasional bloating or gas after meals, appetite may fluctuate, sometimes feeling overly full or unsatisfied after eating, mild discomfort or cramping after some meals, occasional indigestion or heartburn, slight fatigue or sluggishness after eating

Poor: infrequent bowel movements (less than 3 times a week) or diarrhea, stools may be hard/dry/watery, frequent bloating, gas, or abdominal pain after eating, persistent feelings of fullness/nausea / lack of appetite, chronic acid reflux or heartburn, unexplained weight loss or gain, food intolerances or sensitivities, frequently see undigested food in stool

Do you have hemorrhoids?

Do you use enemas or laxatives?

Is your diet:

non-vegetarian (regularly includes meat or fish)

mostly vegetarian (occasionally includes meat or fish)

vegetarian (includes eggs, honey, dairy)

vegan (does not include meat/fish, eggs, honey, dairy)

Other

Do you feel you now have or had in the past an eating disorder?

About what percentage of your food is organic?

What kind of water do you drink?

Approximately how much water do you drink a day?

How many hours do you sleep a night?

What time do you usually go to bed?

What time do you usually wake up?

Do you go to bed and wake up at the same time daily?

Do you eat your meals at the same time daily?

How often do you exercise?

What type of exercise do you do, if any?

Is your exercise:

vigorous

moderate

light

none

How often do you practice meditation?

regularly

occasionally

never

What kind of meditation?

Do you take daytime naps?

Do you travel a lot?

How often do you smoke and/or drink alcohol?

How often do you drink caffeinated beverages?

Are you currently in psychological counseling?

Are you currently exposed to chemicals, pesticides, or live near a powerplant or high tension wires?

Alll information provided in this form is confidential and will be used solely to create your personlized Ayurvedic program.

ANANDA JIVA