First and Last Name (required)

Email Address (required)

Address

City

Zip or Postal Code

State or Province

Country

Occupation ( If Changed)

Home Phone No. (w/ area code)

Work Phone No. (w/ area code)

Date of Birth (mm/dd/yyyy)

Marital Status

What Ayurvedic practices have you been able to incorporate into your lifestyle?

Do you have any questions about any of these practices?

Please describe your main health concern.

Please describe your current emotional state.

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 area of concern would you like to focus on in this visit?

What time do you go to bed? How long does it take to fall asleep? Do you stay asleep?

Additional comments

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?