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Patient Extensive Intake Form -Form Fill

Q2

First Name

Patient Name*
Q3

Middle Name

Patient Name*
Q4

Last Name

Patient Name*
Q5

Date of Birth*
Q6

Street Address

Address*
Q7

Street Address Line 2

Address*
Q8

City

Address*
Q9

State / Province

Address*
Q10

Postal / Zip Code

Address*
Q11

Country

Address*
Q12

Phone Number

Home Phone*
Q13

Phone Number

Work Phone
Q14

Phone Number

Cell Phone*
Q15

Patient E-Mail*
Q16

Current Occupation*
Q17

Emergency Contact*
Q18

Relationship to Patient*
Q19

Phone Number

Emergency Contact Phone Number*
Q20

Why are you interested in an Ayurvedic consultation?*
Q21

Please describe your present health problems and their duration.*
Q22

How long have you had the chronic conditions about which you are consulting us?*
Q23

How have your health problems progressed since they began?*
Q24

Please indicate the overall intensity of your symptoms.*
Q25

Do you take any nonprescription drugs, vitamins and/or any other supplements? Please list them.*
Q26

Are you currently under the care of a family physician or any other health professional? If yes, include details.*
Q27

Do you currently take medication and/or receive medical treatment for your health condition(s)? If so, include all medications, treatments, and dosages.*
Q28

Do you have any past medical history or problems (i.e.. illness, trauma, emotional stress, addictions, drug abuse, or anything else that will help us clearly understand your health condition)?*
Q29

Is there a family history of the health problem(s) listed above? If yes, please specify.*
Q30

Any other family illnesses or concerns? If yes, please specify.*
Q31

Health as a child:*
Q32

Childhood illnesses:*
Q33

Immunizations/vaccinations:*
Q34

Have you ever experienced a reaction to vaccination(s)? If yes, please specify.*
Q35

Do you get up early?
Q36

Hour

At what time?*
Q37

Minutes

At what time?*
Q38

AM/PM Option

At what time?*
Q39

Do you go to bed early?
Q40

Do you sleep during the day?
Q41

How do you generally feel when you wake up in the morning?*
Q42

In what direction does your head point during sleep?*
Q43

How would you describe your experience of sleep?*
Q44

What position do you sleep in?*
Q45

How regularly do you follow your ideal routine (i.e., go to bed early, eat meals on time, exercise regularly)?*
Q46

Describe your bowel movements.*
Q47

Other, please specify
Q48

Bowel nature:*
Q49

Bowet movement associated with (choose those that apply).*
Q50

Do you delay or suppress any of the following?
Q51

Do you travel often? *
Q52

Do you self-massage with oil daily?*
Q53

How often do you excercise?*
Q54

What type of exercise do you do?*
Q55

How long do you excercise each time?*
Q56

Rate the intensity of your excercise.*
Q57

Choose the answer that best describes your eating habits*
Q58

Breakfast*
Q59

Lunch*
Q60

Dinner*
Q61

Snack*
Q62

Do you eat between meals?*
Q63

Do you eat meals at regular times?*
Q64

Which is your biggest meal?*
Q65

Rate your digestion.*
Q66

How much water do you drink per day?*
Q67

Indicate your eating habits.*
Q68

Describe your diet.*
Q69

If you are a nonvegetarian, please indicate the proteins you eat.
Q70

Indicate which best describes your sense of taste (if any).*
Q71

What taste(s) do you like to crave?*
Q72

Are there particular foods that create discomfort when you eat them?*
Q73

Do you practice any type of meditation? If yes, please explain.*
Q74

Do you practice yoga? If yes, please explain.*
Q75

Which type of weather makes you feel most uncomfortable?*
Q76

Are you allergic to any substances?*
Q77

If you smoke cigarettes (or other substances), how many do you smoke per day?
Q78

How often do you drink alchohol?*
Q79

How much at at time?
Q80

How often do you drink caffeinated beverages?*
Q81

How would you rate your usual energy level?*
Q82

Do you experience any of the following?*
Q83

Select the best answer for the the questions asked.*
Q84

As a child, did you experience any abuse or trauma?*
Q85

Type of abuse:*
Q86

Please indicate which of the following areas are troublesome (if any).
Q87

Age menses began:
Q88

Which of the following describes your menstruation?
Q89

How many days does your menstrual period last?
Q90

How is your menstrual flow?
Q91

Do you have any associated symptoms (before or during menstruation?
Q92

Do you have any discharge outside of your menstrual period?
Q93

Do you ever experience pain during intercourse?
Q94

Are you pregnant now?
Q95

Do you have any sexual difficulties?
Q96

If yes, please explain.
Q97

Do you take contraceptive pills or use other forms of birth control?
Q98

Number of previous pregnancies.
Q99

Do you have any history of abortion, miscarriage, or problems related to pregnancy or labor? If yes, explain.
Q100

How many children do you have?
Q101

How old are your children?
Q102

Do you breast self-exam regularly?
Q103

Do you experience any of the following?
Q104

Other comments
Q105

Client Signature*