recipes
about ayurveda

One hour assesment including determination of your Dosha, analysis of your current diet, and suggestions for balanced Ayurvedic diet. $100

ayurvedic light
                 
(please note there is extra space on the last page for additional concerns and comments)
Name Gender
Place of Birth Date of birth
Marital Status # of children
Occupation
Address
Phone Number(s)
Email
Primary Health Care Provider
Primary Health Care Provider Phone Number
       

Please list your main Concerns in order of Importance:
1st Concern
2nd Concern
3rd Concern
       
How, when, and where did these concerns begin?

How do they impair your daily activities?

Have you seen any health professionals seen for these concerns? If so, which?

What would you like to achieve in terms of your health?
Have you had any surgeries? If yes, please describe.
What medications are you currently taking?
What vitamins/supplements are you currently taking?
What non prescription drugs or recreational drugs are you currently taking?
Have you had a history of any disease or other problems?
If you or your family has ever had any of the following check boxes that are applicable.  

Myself

Maternal side

Paternal Side

Myself

Maternal Side

Paternal Side

  

Allergies to Food or drug

Heart Surgery

Anemia

Hepatitis A

Arthritis

Hepatitis B

  

Asthma, Pneumonia

Hepatitis Non-A/Non-B

  

Tuberculosis

HIV Exposure

  

Blood Pressure, High/Low

Hives

  

Cancer

Kidney or bladder disease

  

Chemotherapy/ Radiation treatment

Mononucleosis, Jaundice, Gallstone

  

Chest Pain/ Angina

Pain or Ringing in Ear

  

Dental Treatment Complications

Popping, Clicking, Locking of the Jaw

  

Diabetes

Hemophilia

  

Epilepsy, Convulsions, Seizures

Psychiatric Treatment

  

Fainting

Rheumatic Fever

  

Feet or Ankles, Swelling

Shortness of Breath

  

Glaucoma, Eye surgery

Thyroid Disease or Medication

  

Heart Attack

Ulcers, Intestinal Bleeding

  

Heart Disease/Heart Murmur

Venereal Disease

  

The Next Section is for Women:
Are you pregnant? If yes, for how many months?
# of pregnancies Menopause?
Date of last menstrual period Cycles
# of days between cycles PMS?
Is there pain during cycle?
Is there sickness or weakness during period?
Is there a history of miscarriage?

What birth control method do you use?

  
       
Please use this space for additional comments or concerns: