Intake Form

Patient Information:

(1) Past Medical History

Please list any major condition(s) and dates of diagnosis, treatment, and procedures performed

(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.)

(3) ALCOHOL, TOBACCO AND SUBSTANCE USE

(Note: This will be kept confidential)

(4) REGULAR PRACTICES

(5) RELATIONSHIP

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(6) FOOD CHOICES

(Please be as detailed as possible by listing below what types of foods you eat on a regular basis)

(7) DAILY LIQUID INTAKE

(Indicate number of 8 ounce cups per day)

(8) HABITUAL EATING PATTERNS

Describe any current or past eating patterns or any other food related issues.

(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.
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(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)
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PRACTITIONER USE ONLY:

(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
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ENERGY LEVELS

Describe your energy levels on a scale of 1 to 10: (1 being ‘completely exhausted’ to 10 being ‘great’)
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PRACTITIONER USE ONLY:

Vikruti: Add up Doshic symptoms that are daily or have an intensity of 4 and higher.