Please enable JavaScript in your browser to complete this form.Date: *Patient Information:Name *FirstMiddleLastPhone NumberBirthdate: *(1) Past Medical History Please list any major condition(s) and dates of diagnosis, treatment, and procedures performeda. Are you under the care of a licensed health care professional or any other healthcare provider? *YesNo If so, for what reasons: b. Serious illnesses: c. Hospitalizations: d. Operations: e. List other pertinent current or past conditions: f. Have you had any cosmetic surgery or procedures performed? *YesNoIf so, please list:g. Are you pregnant? *YesNoN/A(2) FAMILY HISTORY Indicate what members of your immediate family have had these conditions. (Go back one generation) (If adopted, answer according to family heritage, if known.) Choice 1High Blood Pressure:Choice 1 DetailsChoice 2Heart Disease:Choice 2 detailsChoice 3Cancer:Choice 3 details Choice 4Mental Disorder:Choice 4 details Choice 5 Stroke:Choice 5 details Choice 6Diabetes:Choice 6 details Choice 7Allergies or SensitivitiesChoice 7 details Choice 8Other:Choice 8 details (3) ALCOHOL, TOBACCO AND SUBSTANCE USE a. Do you drink alcoholic beverages? *YesNoIf yes, how often:DailySeveral times weeklySeveral times monthlySeldomHow many glasses?I usually choose:BeerWineSweet or hard liquorPRACTITIONER NOTES: b. Have you ever smoked tobacco? *YesNoIf yes, how much per day?If you have quit smoking tobacco, what year did you quit? Do you smoke marijuana? *YesNoIf yes, how much per day? PRACTITIONER NOTES: c. Any current or past use of other addictive or habitual substances? *YesNo(Note: This will be kept confidential) Please list all substances (either current or long term past usage):PRACTITIONER NOTES: (4) REGULAR PRACTICESExercise/Hatha Yoga Yes (Specify):Single Line TextMultiple ChoiceNone/NeverOccasional DailySeveral times per weekSeveral times per monthTeam Sports/Recreation Yes (Specify):Single Line Text Multiple Choice None/NeverOccasional DailySeveral times per weekSeveral times per monthTravel Yes (Include commute if applicable):Single Line TextMultiple Choice None/NeverOccasional DailySeveral times per weekSeveral times per monthSpiritual Practices Yes (Specify):Single Line Text Multiple Choice None/NeverOccasional DailySeveral times per weekSeveral times per monthMeditation/Prayer/Pranayama Yes (Specify):Single Line Text Multiple ChoiceNone/NeverOccasional DailySeveral times per weekSeveral times per monthOther Yes (Include creative activities):Single Line Text Multiple Choice None/NeverOccasional DailySeveral times per weekSeveral times per month(5) RELATIONSHIP a. Please indicate how nourished you feel in your relationship (1 being the least nourished, 10 being the most nourished): Selected Value: 1 If not applicable please select:N/A b. How often do you engage in sexual activity (include sex with partner and masturbation):c. Is your current sexual activity satisfactory?YesNoPRACTITIONER NOTES: (6) FOOD CHOICES (Please be as detailed as possible by listing below what types of foods you eat on a regular basis) Breakfast:LunchDinnerSnacksWhat percentage of your food is organic? (7) DAILY LIQUID INTAKE(Indicate number of 8 ounce cups per day) CheckboxesCaffeinated Coffee/Tea:Single Line TextCheckboxes Herbal Tea or Juice:Single Line Text Checkboxes Decaffeinated Coffee/Tea:Single Line Text Checkboxes Soda or Diet Soda:Single Line TextCheckboxesPlain water:Single Line TextCheckboxes Cow or Goat Milk:Single Line TextCheckboxesGrain/Nut/Soy Milk:Single Line Text (8) HABITUAL EATING PATTERNS Describe any current or past eating patterns or any other food related issues.Paragraph Text(9) DAILY SCHEDULE (include approximate times) What are your habitual activities from the time you wake up until you go to sleep? Include mealtimes, sleeping, exercise, work, and any activities that occur on a regular basis. MorningAwakenSingle Line Text (Time:)Morning MealtimeSingle Line Text (Time:)MorningActivitiesSingle Line Text (Time:)HABITUAL ACTIVITIES DayMealtimeSingle Line Text (Time:)Day ActivitiesSingle Line Text (Time:)HABITUAL ACTIVITIES NightMealtimeSingle Line Text (Time:)Night ActivitiesSingle Line Text (Time:)Night Bed-timeSingle Line Text (Time:)HABITUAL ACTIVITIES PRACTITIONER NOTES: (10) AYURVEDIC HISTORY For each category please identify your tendency over time by selecting the box that is most appropriate for you. If you are unsure or would like to speak to your practitioner about this please check the appropriate box. (Practitioners: V = short term tendencies / Vikruti, P = Long-term tendencies / Prakruti)AppetiteI prefer to eat frequently but my hunger level is variable, and I often forget to eat.Practitioner use onlyVPAppetiteI have a strong appetite I prefer to eat 3x/day and rarely skip meals.Practitioner use only VPAppetite I prefer to eat 2-3x/day, but I can go without eating with no discomfort.Practitioner use onlyVPAppetite I'd like to discuss this with my practitionerPractitioner Use Only NotesAppetiteIf I miss a meal, I often get light-headed, anxious or cranky.Practitioner use onlyVPAppetite If I miss a meal, I often get critical or angry.Practitioner use only VPAppetiteIf I miss a meal, it doesn’t really bother me.Practitioner use onlyVPAppetiteI'd like to discuss this with my practitionerPractitioner Use Only (Frequency/Intensity) Selected Value: 1 DigestionAfter eating, I often experience gas or bloatingPractitioner use onlyVPDigestionAfter eating, I often experience heartburn or acidity.Practitioner use only VPDigestionAfter eating, I often feel heavy or sleepy.Practitioner use only VPDigestionI'd like to discuss this with my practitionerPractitioner Use Only (Frequency/Intensity) Selected Value: 1 EliminationI tend to have irregular bowel movements one time per day or less.Practitioner use onlyVPEliminationI tend to have 1 or more bowel movements daily, usually with regularity and ease.Practitioner use onlyVPElimination I tend to have one bowel movement per day with no straining or difficulty.Practitioner use onlyVPElimination I'd like to discuss this with my practitionerPractitioner Use Only (Frequency/Intensity) Selected Value: 1 EliminationMy bowel movements are often dry and hard. At times I may strain or push.Practitioner use only VPElimination My bowel movements are usually well-formed, but sometimes they are loose and may burn.Practitioner use onlyVPEliminationMy bowel movements are usually well-formed, slow and easy.Practitioner use onlyVPEliminationI'd like to discuss this with my practitionerPractitioner Use Only (Frequency/Intensity) Selected Value: 1 WeightI usually don’t gain weight very easily.Practitioner use only VPWeightWhen I gain weight, it is easy to lose it.Practitioner use only VPWeight I gain weight easily and lose it slowly.Practitioner use only VPWeightI'd like to discuss this with my practitionerPractitioner Use Only (Frequency/Intensity) Selected Value: 1 Body TemperatureMy hands and feet often feel cold, and I prefer warmer climates.Practitioner use only VPBody TemperatureI am warm most of the time no matter what the climate is.Practitioner use onlyVPBody TemperatureI adapt easily to most conditions, but tend to feel coolPractitioner use onlyVPBody TemperatureI'd like to discuss this with my practitionerPractitioner Use Only (Frequency/Intensity) Selected Value: 1 SleepI tend to sleep lightly and awaken very easily. It can be difficult for me to go to sleep.Practitioner use onlyVPSleepI tend to sleep soundly and awaken with ease.Practitioner use onlyVPSleep My sleep tends to be deep and long. It can be difficult for me to awaken in the morning.Practitioner use onlyVPSleepI'd like to discuss this with my practitionerPractitioner Use Only (Frequency/Intensity) Selected Value: 1 StressUnder stress I often become worried or overwhelmed.Practitioner use onlyVPStress Under stress I often become irritable, but usually rise to the challenge.Practitioner use onlyVPStress Under stress, I often withdraw to observe or become reclusive.Practitioner use only VPStressI'd like to discuss this with my practitionerPractitioner Use Only (Frequency/Intensity) Selected Value: 1 Decision makingI am changeable and often have difficulty making decisions.Practitioner use onlyVPDecision makingI make decisions easily, but can change my mind with new information.Practitioner use onlyVPDecision makingI am careful but easy-going about decisions.Practitioner use onlyVPDecision MakingI'd like to discuss this with my practitionerPractitioner Use Only (Frequency/Intensity) Selected Value: 1 ProjectsI like to start projects, but at times have difficulty finishing them.Practitioner use only VPProjects I like to start and finish projects. Completion is important to me.Practitioner use only VPProjectsI like working on a project, but prefer to let others start them.Practitioner use only VPProjectsI'd like to discuss this with my practitionerPractitioner Use Only (Frequency/Intensity) Selected Value: 1 PersonalityWhen I am balanced I feel creative, enthusiastic, and vivacious.Practitioner use only VPPersonality When I am balanced I feel perceptive, disciplined, and logical.Practitioner use only VPPersonality When I am balanced I feel nurturing, calm, and devotional.Practitioner use onlyVPPersonalityI'd like to discuss this with my practitionerPractitioner Use Only (Frequency/Intensity) Selected Value: 1 PRACTITIONER USE ONLY:V PRAKRUTI: P PRAKRUTI: K PRAKRUTI: V VIKRUTI: P VIKRUTI:K VIKRUTI: (11) CHALLENGING PATTERNS Please indicate any physical and emotional patterns that you find challenging by assigning a Frequency (times per week, month, or year and a number from 0 to 10+) and Intensity (a number from 1 to 10). Example: 3x week or 6x year. 1 TO 3 = MILD DISCOMFORT 4 TO 6 = MODERATE DISCOMFORT 7 TO 10 = SEVERE DISCOMFORT 1 TO 3 = MILD DISCOMFORT 4 TO 6 = MODERATE DISCOMFORT 7 TO 10 = SEVERE DISCOMFORT A. DigestionExcessive belchingFrequency (week, month, year)Frequency (week, month, year)Intensity 1-10 Selected Value: 1 A. DigestionExcessive gasFrequency (per week)Frequency (week, month, year)Intensity 1-10 Selected Value: 1 A. Digestion Acid RefluxFrequency (per week) Frequency (week, month, year) Intensity 1-10 Selected Value: 1 A. Digestion Burning indigestionFrequency (per week) Frequency (week, month, year) Intensity 1-10 Selected Value: 1 A. DigestionNausea or vomitingFrequency (per week)Frequency (week, month, year) Intensity 1-10 Selected Value: 1 A. DigestionSleepy after eatingFrequency (per week)Frequency (week, month, year) Intensity 1-10 Selected Value: 1 A. DigestionHeaviness after eatingFrequency (per week)Frequency (week, month, year) Intensity 1-10 Selected Value: 1 A. Digestion Bloated after eatingFrequency (per week)Frequency (week, month, year) Intensity 1-10 Selected Value: 1 Patient CommentsB. EliminationConstipation (less than 1 BM/day)Frequency (per week)Frequency (week, month, year) Intensity 1-10 Selected Value: 1 B. Elimination Alternating constipation & diarrheaFrequency (per week) Frequency (week, month, year) Intensity 1-10 Selected Value: 1 B. Elimination Food particles in stoolFrequency (per week)Frequency (week, month, year) Intensity 1-10 Selected Value: 1 B. EliminationDiarrheaFrequency (per week)Frequency (week, month, year) Intensity 1-10 Selected Value: 1 B. EliminationRectal pain or hemorrhoidsFrequency (per week)Frequency (week, month, year) Intensity 1-10 Selected Value: 1 B. Elimination Mucus in stoolFrequency (per week) Frequency (week, month, year) Intensity 1-10 Selected Value: 1 B. Elimination Abdominal painFrequency (per week) Frequency (week, month, year) Intensity 1-10 Selected Value: 1 Patient CommentsC. EmotionsWorryFrequency (per week) Frequency (week, month, year) Intensity 1-10 Selected Value: 1 C. EmotionsAnxietyFrequency (per week) Frequency (week, month, year) Intensity 1-10 Selected Value: 1 C. Emotions OverwhelmFrequency (per week)Frequency (week, month, year) Intensity 1-10 Selected Value: 1 C. Emotions Self-destructivenessFrequency (per week)Frequency (week, month, year) Intensity 1-10 Selected Value: 1 C. Emotions AngerFrequency (per week)Frequency (week, month, year) Intensity 1-10 Selected Value: 1 C. EmotionsResentmentFrequency (per week)Frequency (week, month, year) Intensity 1-10 Selected Value: 1 C. EmotionsCritical/BlamingFrequency (per week)Frequency (week, month, year) Intensity 1-10 Selected Value: 1 C. Emotions IntenseFrequency (per week) Frequency (week, month, year) Intensity 1-10 Selected Value: 1 C. EmotionsLethargicFrequency (per week) Frequency (week, month, year) Intensity 1-10 Selected Value: 1 C. EmotionsMelancholyFrequency (per week)Frequency (week, month, year) Intensity 1-10 Selected Value: 1 C. EmotionsDepressionFrequency (per week)Frequency (week, month, year) Intensity 1-10 Selected Value: 1 C. EmotionsStubbornnessFrequency (per week)Frequency (week, month, year) Intensity 1-10 Selected Value: 1 Patient CommentsENERGY LEVELSDescribe your energy levels on a scale of 1 to 10: (1 being ‘completely exhausted’ to 10 being ‘great’) Number Slider Selected Value: 1 Patient CommentsPRACTITIONER USE ONLY: Vikruti: Add up Doshic symptoms that are daily or have an intensity of 4 and higher. V VIKRUTI: P VIKRUTI: K VIKRUTI:Additional NotesParagraph TextParagraph TextSubmit