Yoga, Therputic oil or Marma | Elemental Ayurveda L

Pre-appointment forms

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

Height and weight

Present concerns and Goals of your visit

Other conditions presently bothering, even if not the focus of your visit. State how long they have persisted. Be sure to state if High/ Low BP.

Past medical history

Medications present and past.

Family medical history – father/ mother/ siblings.

Briefly describe your Appetite? How is your hunger level before meals - regular, mild, sharp hunger?

Briefly describe your digestion. How do you feel post meal -energised, heavy, lethargic, bloated, gassy, nausea, congestion?

Briefly describe your elimination/ bowel movement. Egs - happens daily with ease or tendency towards constipation or diarrhoea.

Hydration - how many glasses of water do you drink a day? How is your thirst, urination and sweat? Mention if you have excess/ scanty thirst, excess/ scanty urination and or sweat?

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

How is your mental/ emotional state? Rate it on a scale of 1 – 10 where 10 is the highest level.

Do you have any pain in your body? Rate it on a scale of 1 – 10 where 10 is highest level. Where is it located? Does it move, throb, is it dull or constant? What relieves pain?

Do you have any physical limitations?

Please confirm whether you are pregnant at this time.

If doing a Yoga, Pranayama, meditation session please share whether you currently practice them - how recently and how frequently.

If you have a current Yoga/ Pranayama routine, please specify the breathing exercises or meditations you do and how frequently.

For Yoga/ Pranayama Session please share how much time per day you can spend/ would like to spend on your routine. Please check those that apply.

I only have 15 mins a day

15 - 30 minutes a day

Would like to have a 30- 60 minute plan that I will work towards.

For Yoga/ Pranayama Session. Please specify if you would like the practitioner to create a routine for you that includes yoga asanas/ poses, pranayama/ breathing exercises and meditation. Please specify if you do not want any of these.

If doing a Therapeutic Oil OR Marma treatment. Please check those that apply.

I am allergic to any oils?

I am allergic to flour/ chickpea dough?

I am not able to lie on my abdomen for 45 - 60 mins.

I do not have any open wounds, cuts on your body in the area of the treatment.

Have you had an Ayurvedic treatment before? If so, which one?

Please add any additional information you would like to share with the Ayurvedic Practitioner.

I understand that I should not eat for 1 - 1.5 hours before my yoga or oil session.

I have answered all questions accurately and declared all conditions I have.

Pre-appointment forms

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