New Client Intake Form | Elemental Ayurveda L

Full Name & Address

Phone Number & Email address

Place of Birth, Date of Birth and Age

Gender by birth

Relationships - Are you married, single, in a relationship? Do you have children? If so, what are their ages?

Height and weight – Mention height and weight. Include details if any sudden changes in weight.

Present your concerns & goals. Include specific issues you want to address. Examples include lower back pain, anxiety, or more chronic issues like insomnia, diabetes, auto immune diseases or rejuvenation or how to manage aging.

Other conditions presently bothering you even if not the focus of your visit. Specify these and state how long they have persisted?

Past medical history of any other issues? Include if there is personal history of any additional issues including but not limited to operations/ surgeries. Specify if under physician’s care. If so, how long?

Medications present and past.

Family medical history – father/ mother/ siblings. Include issues ranging from BP, diabetes, cholesterol, heart issues, cancer, auto immune diseases.

How is your appetite/ hunger level before meals? Check those that apply.

Regular, am hungry.

Irregular, like to snack all day.

Low to mild hunger.

Sharp hunger, get hangry if don't eat on time.

How do you feel post meals? Check those that apply.

Energised and light.

Heavy and lethargic. Need to nap.

Bloated and gassy

Acidity and heartburn

Describe your elimination/ bowel movement. Check those that apply.

Daily bowel movement with satisfaction.

Tendency towards constipation.

Tendency towards diarrhoea/ lose stool?

Do you have any allergies? Could be food, medical or environmental.

Do you have any skin conditions? Please specify. Issues could include acne, Dermatitis, Hives/ Urticaria, Psoriasis, Varicose veins, Oedema/swollen feet/ ankles, Skin patches/ discolouration, Skin tags, Lipomas.

Do you have any muscular skeletal issues? Could include cysts, tumours, spurs, bursitis, tendonitis, joint issues, popping, cracking, stiffness, sciatica, osteopenia/ porosis/ arthritis, RA, GOUT, MS, Myalgia, Back issues.

Do you have any pain in your body? Where is it located? Rate it on a scale of 1 - 10 where10 is the highest. Describe the pain, check those that apply.

It moves or travels.

It feels hot to the touch.

It is dull and deep.

It is constant.

Heat helps.

Cold helps.

It wakes me at night.

Do you drink, smoke or take drugs? Please specify what, how much, how often and for how many years.

Do you exercise? If so, then how frequently and what kind of exercise do you do?

How are your energy levels? On waking in the morning and during the day.

How is your sleep? Are you a heavy/ light sleeper? do you have insomnia? Light sensitive? Difficulty falling asleep/ staying asleep? Trouble waking in the morning? Daytime napper?

How is your mental/ emotional state? Are you dealing with stress, intense anger, anxiety, panic attacks, loneliness, grief, depression, suicidal ideation, memory loss or confusion? Rate on a scale of 1 – 10 where 10 is the highest level.

Women Only - please state the age your menstruation began. Explain if you have any menstrual concerns. Are you taking birth control?

Women Only - are you pregnant, number of pregnancies, abortions, miscarriages. Explain if any complications.

Women Only - Peri/ Menopause. Do you have any specific concerns here? If so explain. Specify if you are on HRT/ Bio identicals and if oral or creams.

Women Only - Specify if you have had a hysterectomy or prolapse or other surgeries.

Do you have any physical limitations?

Any additional information you would like to share with the practitioner?

New Client Consult Forms

Liability Waiver

Client History

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