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Welcome to Your Ayurveda Journey

Below, you’ll find everything you need to begin—what to expect, how we’ll work together, and the steps to prepare for our first session.

Let's get started!

Today's Date
Month
Day
Year
Gender Identity
Female (She / Her / Hers)
Male (he/him/his)
They / Their / Them
Prefer not to say
Other
Date of Birth
Month
Day
Year
Your status. Please check all that apply.

MEDICAL HISTORY

Please answer all to the best of your ability

Do you experience any of the following:
Do you have a primary care physician?
Yes
No
Do you smoke?
Do you drink alcohol?
No
Daily
Weekly
Monthly
Special Occasions
Other
Do you travel frequently? Check all that apply:
Which type of weather makes you feel most uncomfortable?
Hot
Cold
Cool and Damp
What is your body type?
Thin
Average
Large
Muscular
Are you overweight?
No
Yes
Other
Do you have any significant Family Medical History, including but not limited to: parents, grandparents, siblings, children? Please check all that apply:
How was your health as a child?
Good
Fair
Poor
Check all that apply from your Childhood Medical History:
Do you suppress any of these Natural Urges? Please check all that apply:

SLEEP

Please answer all to the best of your ability

On average, what time do you go to bed?
Time
HoursMinutes
On average, what time do you wake up?
Time
HoursMinutes
How do you feel when you first wake?
Fresh, well rested
A little tired
Very tired
Groggy
Hit snooze multiple times before getting out of bed
Do you sleep during the day?
No
Sometimes
Frequently
How would you rate your sleep? Check all that apply:
Do you snore?
Yes
No
Sometimes
I don't know
Are you a mouth breather?
Yes
No
Do you experience "restless leg syndrome"?
Never
Often
Sometimes

ENERGY

Please answer all to the best of your ability

How would you rate your usual / daily / average Energy Level?
Very High
High
Moderate
Low
Very Low
Is your energy consistent throughout the day?
Yes
No
If your energy is inconsistent, when does your energy dip?
In the morning
In the Afternoon between 2 - 4pm
Other

EXERCISE

Please answer all to the best of your ability

Do you exercise regularly?
Yes
No
How often do you exercise?
Never
Daily
1-2 days a week
3-4 days a week
5 days a week or more
At what level do you most often exercise?
Light
Moderate
Vigorous
Do you have consistent energy throughout your exercise routine?
Yes
Usually not
Are you able to still speak while you exercise?
Yes
No
Do you practice any of the following modalities? Please check all that apply:

APPETITE + DIGESTION

Please answer all to the best of your ability

How regular is your daily routine?
Very regular
Somewhat regular
Irregular
Which is your biggest meal of the day?
Breakfast
Lunch
Dinner
Do you feel hungry before each meal?
Yes, all of the time
Sometimes
Never
How do you eat your meals? Please check all that apply:
Do you feel satisfied after eating your meals?
Yes
No
I'm not sure
Do you regularly skip meals?
No
Daily
Sometimes
Do you eat in between meals?
Daily
Occasionally
Never
How often do you prepare your own meals with fresh ingredients?
Daily
Weekly
Never
Other
Do you enjoy cooking?
Yes, I love to cook
Not really
How often do you eat out or get take out?
Never
Daily
Weekly
Monthly
How often do you eat fast food?
Never
Daily
Weekly
Monthly
Describe your diet. Please check all that apply:
What tastes do you like or crave? Check all that apply:
What tastes create discomfort when you eat them? Check all that apply:
Please rate your digestion:
Fair
Good
Poor
Do you currently experience any of the following? Please check all that apply:
How often are your bowel movements? Please check all that apply:
Do you frequently see food particles in your stool?
Yes (list what you see under "other")
No
Other
Is your bowel movement regularly associated with any of the following:
What is the nature of your bowels? Please check all that apply:
How often do you urinate each day?
1-3x per day
4-5x per day
More than 5x per day
Do you frequently urinate during the night?
No
Yes
How do you consume water with your meals? Check all that apply:
How do you consume water, outside of your meals? Check all that apply:
Do you experience any of the following with urination? Check all that apply:
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