Follow Up Consult Form | Elemental Ayurveda L

Follow Up Consult

Ahead of your appointment, please be sure to fill out this form so we can best understand your needs

Full Name & Address

Phone Number & Email address

Date of Birth and Age

Gender at Birth

Height and weight - Mention if any sudden changes in weight since initial consultation.

Reason for your follow up visit? Could be new concerns, Check in, for refill herbs.

Briefly state your previous concerns with a brief status update on how you are doing since initial consultation.

Any new concerns that have arisen/ issues you would like to discuss?

Other conditions presently bothering you even if not the focus of your visit. This could include but is not limited to blood pressure issues, diabetes, cholesterol, auto immune diseases, cardiac issues. How long have they persisted?

Have you been following diet and lifestyle recommendations? This is just for the practitioner to know so please be as honest as possible. No judgement here as we all have demanding lives.

Have you been taking herbs, applying oils, etc ? Explain how consistent you have been and if you have seen any changes.

Briefly describe your appetite and if it has changed? What is you hunger level before meals? Regular, mild, sharp hunger.

Briefly describe your digestion and if it has changed? How do you feel post meal? Energised, heavy/ lethargic, bloated/ gassy, acidity/ heartburn?

Briefly describe your elimination/ bowel movement. Has it changed? Do you have a Bowel movement daily with satisfaction or a tendency towards constipation or a tendency towards diarrhoea/ lose stool.

How is your thirst, urination and sweat? Has it changed? State approximately how many glasses of water do you drink a day. Do you have excess/ scanty urination and or sweat?

Do you have any new allergies? Please restate previously mentioned allergies and new ones. Could be food, medical or environmental.

How is your mental/ emotional state? Has it changed? Are you dealing with stress, anxiety, loneliness, grief, depression, insomnia, etc. Please clarify. Rate it on a scale of 1 – 10 where 10 is highest level.

Do you have any pain in your body? Has it changed? Please describe. Rate it on a scale of 1 – 10 where 10 is highest level.

Any other concerns you would like to share with the practitioner.

Follow Up Consult

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