Mini Ayurvedic Intake Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This is a mini consultation form, helpful to get an idea of any imbalance that may be happening.

Name *

Email *

DOB

YYYY

Please list reason(s) for seeking consultation today? What is or has been happening that we can provide support.

Any major medical concerns?

Medications/supplements

If faced with a confrontation (general) how do you respond? *

Flee, I get out of that situation ASAP and move on to something else.

Fight, Nobody's going to get one over on me

Freeze, I retreat and shut down, and stew over the situation for quite some time.

Under Stress I become? *

Anxious and/or worried

aggressive and/or irritable

Withdrawn and/or reclusive

I speak

Fast and/or I love to talk, a lot

My words a consise and to the point

I talk slowly and pretty calmly

Clear selection

Which sound most like you? *

I can be indecisive I adapt to most situations well

I get jelous and /or competitive easily

I'm stubborn, I'm not changing I like thing the way I like things.

What is your favorite season/Temperature?

Summer! the hotter the better! I love 90 degrees!

Fall/winter I love cool and dry. I turn miserable when the heats at 80+ and the humidity gets turned on.

fall I like cool and dry, good napping weather!

Clear selection

My digestion is? *

Irregular, I get constipated often.

A little quick, food can often move right through me

Slow but most of the time on schedlue

How many bowel movements per day (on average).

Every other day.

Once or twice a day

Three or more times a day

First thing in the morning

Immediately after meals

Sleep? *

HA! I have a hard time sleeping my brain never shuts off. It's short and/or broken

Good sound sleeper.

Deep and Long. When it comes to sleep I'm a champ

What time do you wake up in the morning?

What time do you go to bed at night?

Schedule? *

What's that? If I have one it is irregular and spontanious.

Organized to the half hour and purposeful. I don't deviate from it unless I find the change benificial.

Same routine every day, it's not going to change don't try. and it's full of lists and set in stone.

Food/eating *

Oops, I forgot to eat today... oh well, look shiny objects!

Look up HANGRY, that's a picture of me. Bad things happen when I miss a meal.

I have a habit of emotional eating. Don't get me wrong I eat but a lot of the time I don't want breakfast till about 10am if at all. But give me a tub of ice cream and a Law and Order marathon and that Ice cream is gone! A long with the day.....

What does your breakfast typically look like?

What does your lunch typically look like?

What does your dinner typically look like?

My Energy level *

Fluctuates, often comes in bursts. I move a lot and get fatigued pretty easy.

I have good energy, driven, purposeful. My determination will sometime exhaust me because I must win (even at doing the dishes...)

I have good energy and stamina, Whether or not I use it is another story.

How often do you exercise?

Daily

Twice a week

Three times a week

Four times a week

Not at all

What type of exercise do you do?

Illness/cold/flu *

If its out there I get it. it comes and goes quickly and then I'm on the the next one.

I'm pretty resilient, if I get a cold it runs it's course and is gone fairly quick. (I don't have time for colds)

If I get a cold or flu I hold on to that bad boy for weeks! Lots of congestion.

Which word do you relate to the most? *

Spontaneous

Driven

Quiet

Do you have any questions?

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms