Name
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First Name
Last Name
Email
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Phone
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Date & Time of Birth
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MM
DD
YYYY
Birth Location
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Gender Identity
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Emergency Contact
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What encouraged you to want to meet with an Ayurveda Wellness Coach?
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How long has this been bothering you?
What are the biggest challenges, in regard to your health and wellness, that you are experiencing right now? How long have you been experiencing them?
We begin our understanding of Self with exploring patterns, family histories, and physical functions in the body. This Intake serves as a starting point for understanding and shifting into greater harmony. Are you currently working with a health care professional?
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For how long? are you noticing any improvement in systems?
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Are there any past medical conditions (i.e., illness, trauma, addictions, excessive stress, anything else) that could help us better understand your health and create a plan for lifestyle changes?
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Tell us about your mother’s health. Check the appropriate boxes below.
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Tell us about your father’s health. Check the appropriate boxes below.
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Please use this space to provide details about what you have checked in the family health history:
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How would you describe your health during childhood?
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Now that we have explored your current and prior health concerns and discussed family history, let’s review your current sleep, relationships, and diet routines. How would you describe your daily routine most days?
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Is it different from your ideal routine?
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What time do you get up in the morning? Is it the same every morning?
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How do you feel when you wake up in the morning (i.e., well rested, tired, etc.)?
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How would you describe the quality of your sleep? Do you wake up frequently, have trouble falling asleep, experience nightmares, sleep soundly?
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Do you nap during the day?
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What time do you go to bed? Is it the same every night?
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What does your evening look like a few hours before you go to bed?
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Is there anything else you would like to share about your sleep routine?
How often do you ingest carbs during a typical week?
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How often do you ingest vegetables during a typical week?
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How often do you ingest meats during a typical week?
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How often do you ingest fruits during a typical week?
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How often do you ingest dairy products during a typical week?
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How often do you ingest alcohol during a typical week?
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How often do you ingest coffee during a typical week?
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How often do you ingest tea during a typical week?
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How often do you ingest soda (including diet) during a typical week?
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How often do you ingest sugar during a typical week?
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How often do you ingest tabacco during a typical week?
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How often do you ingest recreational drugs during a typical week?
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How many glasses of water are you drinking per day?
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Do you enjoy cooking? how often do you cook for yourself?
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Have you ever had any food addictions, eating disorders or related patterns around food?
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Describe what you typically eat for breakfast
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Describe what you typically eat for lunch
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Describe what you typically eat for dinner
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When is your biggest meal of the day?
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Describe your habits while eating (Do you eat with your full attention on food? While watching television? Sitting at the table? Do you eat quickly?)
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Are you currently being prescribed any herbs or medications? Please list:
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Are there certain tastes you crave? Sweet, salty, sour, bitter, hot/spicy, oily
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Do you eat between meals? What do you typically snack on?
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Are you hungry upon waking?
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Do you experience any of the following symptoms after eating?
Please elaborate on any symptoms selected in regard to their frequency, intensity & typical source of disturbance:
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What most accurately describes your elimination pattern:
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Specify from above
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Are your stools (check all that apply)?
Please specify
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Do you travel frequently? Please describe:
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Do you have a commute? Please describe:
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What sorts of exercise/ movement do you participate in?
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How often do you exercise?
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How long do you exercise each time?
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Rate the intensity of your typical exercise:
Is there anything else you would like to share about your diet and exercise?
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Current relationship status, or most recent relationship:
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If currently in relationship, how would you describe the quality of this relationship? Elaborate.
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How would you describe your past intimate relationships?
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At what age did you become sexually actively?
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What would you say is the past and present state of your sensual health?
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Are you sexually active now? (With or without a partner)
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Are you satisfied with your sex life? What would you like to be different?
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Would you consider your cycle regular? If no, please provide additional information.
When was the first day of your last menstrual cycle?
How long does your menstruation typically last?
Is your menstrual flow typically light, heavy or moderate? Please describe:
Do you have cramping or pain? Does it vary during different parts of your cycle?
Around the time of, or during your menstrual cycle do you experience any of the follow: changes in mood, weight gain, acne or rashes, cravings, fatigue, depression, anxiety, yeast, breast tenderness, bloating, intense dreams, etc. (Please circle, add other symptoms, and use extra space provided if explanation is needed)
Do you use products made of natural materials during your cycle?
Are you experiencing any symptoms of Menopause and Perimenopause (i.e., hot flashes, mood swings, difficulty sleeping, vaginal dryness, and loss of libido)? Please circle and use the space to provide explanation if needed.
What method are you currently using for contraception?
Are you using, or have you ever used, hormonal contraceptives like the pill, patch, ring or other? Do you, or have you ever, used an IUD for contraception?
Have you ever experienced side effects while using any of the above methods of birth control?
Are you, or have you ever used bio-identical hormones?
Are you, or have you ever been pregnant?
Are you, or have you ever been pregnant?
Number of times you have been pregnant? Have you ever miscarried?
Have you ever experienced complications during pregnancy, delivery, or after giving birth? Please describe
Has anyone in your family ever been diagnosed with a mental illness?
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Have you ever been treated for, diagnosed with or experienced symptoms of mental illness?
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Explain your current emotional experience with feeling anxious including intensity, frequency, and related incident if known
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Explain your current emotional experience with feeling Self destructive including intensity, frequency, and related incident if known
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Explain your current emotional experience with feeling overwhelmed including intensity, frequency, and related incident if known
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Explain your current emotional experience with feeling resentment including intensity, frequency, and related incident if known
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Explain your current emotional experience with feeling anger including intensity, frequency, and related incident if known
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Explain your current emotional experience with feeling depressed including intensity, frequency, and related incident if known
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Explain your current emotional experience with feeling intense including intensity, frequency, and related incident if known
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Explain your current emotional experience with feeling melancholy including intensity, frequency, and related incident if known
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Explain your current emotional experience with feeling stubborn including intensity, frequency, and related incident if known
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Explain your current emotional experience with feeling lonely including intensity, frequency, and related incident if known
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Explain your current emotional experience with feeling irritated including intensity, frequency, and related incident if known
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Explain your current emotional experience with feeling fear or panic including intensity, frequency, and related incident if known
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Explain your current emotional experience with feeling high levels of stress including intensity, frequency, and related incident if known
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Explain your current emotional experience with feeling lethargy including intensity, frequency, and related incident if known
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Explain your current emotional experience with feeling worry including intensity, frequency, and related incident if known
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Please use this space to provide details about what you have checked above:
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How well do you believe you handle stress?
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What are some of the ways you currently manage stress right now?
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Have you ever been addicted to any substance? What and for how long?
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Do you currently work? What kind of work?
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Do you enjoy the work you do?
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How would you describe your typical schedule of major activities during the week (i.e., school, work, activities with children, etc.)? Break down each day.
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Do you have hobbies you enjoy?
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How often do you get to participate in them?
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What are you most passionate about?
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Are there spiritual practices, such as prayer, meditation, or others that are important to you?
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What is your current relationship to Spirit/God/Divine/Nature? How does this relationship look for you?
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Do you have other rituals or cultural practices you would like us to know about?
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