Exam Form Ayurvedic Consultation Initial Exam Form First and Last Name (required) Email Address (required) Address City Zip or Postal Code State or Province Country Occupation Home Phone No. (w/ area code) Work Phone No. (w/ area code) Date of Birth (mm/dd/yyyy) Marital Status Please describe your main health concern. Please describe your current emotional state. Are you taking any medication? If so, please list. Have you ever had any surgery? Please list type(s) and date(s). Please describe your digestive system. Do you feel comfortable after eating? How often do you have a bowel movement? What is the consistency of your bowel movements? Have these changed from your past habits? What is your blood pressure? What is your cholesterol level? What time do you go to bed? How long does it take to fall asleep? Do you stay asleep? How tall are you? What do you weigh? What is your ideal weight? Do you smoke? If so, how many per day? Do you drink alcohol? If so, how much and how often? Do you practice any form of Meditation? How did you hear of Dr. Cravatta For Women Only*: Please describe your menstrual cycle. (Is it regular, do you experience cramps, PMS, anything else?) Indicate the date of your last menstrual period. Have you ever been pregnant? How many times? Do you have children? If so, what are their ages? What type(s) of birth control do you currently use? Also please explain what type(s) of birth control you have used in the past? 10-3=? Please read this disclaimer before submitting your form:By clicking the “Submit Form” button below, I am indicating that I understand that this Ayurvedic consultation is to help me gain a greater sense of happiness and personal well-being and is not intended to diagnose or treat disease. If I have a persistent problem it is my responsibility to seek appropriate medical care. Use of our services does not replace medical consultation with a qualified health or medical professional to meet the medical needs of you and/or others.Dr. Mary Jo Cravatta’s Ayurvedic Center NOTE: Have you forgotten anything? Please double check your form before clicking submit.