AYURVEDA NEW PATIENT INTAKE FORM 4847 Meadows Rd. #153 Lake Oswego, OR 97035 phone (971) 330.8778 fax (971) 330.8579 Page 1 of 11 Present Health Please describe your present health problems: 1. 2. 3. How long have you had the chronic conditions about which you are consulting us? Less than 6 months More than 5 years 6 months to 2 years 2-5 years How has your health problems progressed since they began? Stable Fluctuating Gradually improving Gradually worsening Rapidly improving Rapidly worsening Please indicate the overall intensity of your symptoms: Mild Very severe Moderate Severe How often are you having pain or discomfort? Less than once per week Several times per day Several times per week Most of the time Once a day Patient Information Name: Birthday: Age: Sex: M F Address: City: State: Zip: E-mail Address: Primary Phone: Phone Type: Home Mobile Work Occupation: Employer: How long? Marital Status: Single Married Partnered Separated Divorced Widowed Live With: Spouse Partner Parents Children Friends Alone Pets Emergency Contact: Phone Number: Whom may we thank for referring you to our office?
Transcript
AYURVEDA NEW PATIENT INTAKE FORM
4847 Meadows Rd. #153 Lake Oswego, OR 97035 phone (971) 330.8778 fax (971) 330.8579 Page 1 of 11
Present Health
Please describe your present health problems:
1.
2.
3.
How long have you had the chronic conditions about which you are consulting us?
Less than 6 months
More than 5 years
6 months to 2 years
2-5 years
How has your health problems progressed since they began?
Stable
Fluctuating
Gradually improving
Gradually worsening
Rapidly improving
Rapidly worsening
Please indicate the overall intensity of your symptoms:
Mild
Very severe
Moderate
Severe
How often are you having pain or discomfort?
Less than once per week
Several times per day
Several times per week
Most of the time
Once a day
Patient Information
Name:
Birthday: Age: Sex: M F
Address:
City: State: Zip:
E-mail Address:
Primary Phone: Phone Type: Home Mobile Work
Occupation: Employer: How long?
Marital Status: Single Married Partnered Separated Divorced Widowed
Live With: Spouse Partner Parents Children Friends Alone Pets
Emergency Contact: Phone Number:
Whom may we thank for referring you to our office?
Page 2 of 11
Medical History
Are you currently under the care of a family physician or any other health professional? If yes, include details below.
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(s))?
Is there a family history of the health problem(s) listed above? Yes No If yes, please specify below.
Are you presently taking any medications? If yes, please list:
MEDICATION NAME DOSE REASON STARTED?
Are you presently taking any vitamins or supplements? If yes, please list:
SUPPLEMENT NAME DOSE REASON STARTED?
Do you have any allergies to medications?
Type of reaction?
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Family History Please If a family member currently has, or has had, any of the following conditions listed
below.
CONDITION NAME WHO? CONDITION NAME WHO?
Anemia Hives
Cancer Kidney Disease
Diabetes Mental Illness
Epilepsy Rheumatoid Arthritis
Glaucoma Tuberculosis
Heart Disease Syphilis
High Blood Pressure Stroke
Hay Fever Other:
Childhood Health
How was your health as a child?
Good Fair Poor
Please check any childhood illnesses you had:
German Measles
Scarlet Fever
Other:
Measles
Bronchial Problems
Mumps
Diphtheria
Which immunizations/vaccinations did you have:
Smallpox
Mumps
Other:
Polio
Tetanus
Typhoid
Influenza
Have you ever experienced a reaction to a vaccination(s)?
Yes No
If yes, to which one and the reaction:
Daily Routine
Do you get up early? Yes No At what time?
Do you go to bed early? Yes No At what time?
Do you sleep during the day? Yes No At what time?
How do you feel when you wake up in the morning?
Fresh and rested
Very tired
A little tired
Moderately tired
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In which direction does your head point during sleep?
North
West
Southeast
East
Northeast
Southwest
South
Northwest
How would you describe your experience of sleep?
Sound; normal duration
Too heavy and/or long
Awaken too early
Light; interrupted
Difficulty falling asleep
Frequent nightmares
Not enough
Difficulty waking up
What position do you sleep in?
On back
Right side
On stomach
Other:
Left side
How regularly do you follow your ideal routine (i.e. go to bed early, eat meals on time, exercise regularly)?
Very regularly Somewhat regularly Irregularly
Describe your bowel movements.
Once every 2-3 days
Late in daytime
Need laxative daily
Once daily
Immediately after meals
Other:
First thing in the morning
Immediately after dinner
Describe your bowel nature.
Soft Medium Hard
Do you have any bowel movements associated with:
Pain
Foul smell
Blood
Other:
Mucous
Do you delay or suppress any of the following?
Sleep
Burping
Sneezing
Semen
Bowel movements
Urination
Thirst
Hunger
Gas
Yawning
Breathing
Tears
Do you travel often? Yes No
Do you do self-massage with oil daily? Yes No
Exercise
How often do you exercise?
Daily
Weekly, twice
Weekly, four times
Weekly, once
Weekly, three times
None
What type of exercise do you do?
How long do you exercise each time?
Rate the intensity of your exercise. Light Moderate Vigorous
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Eating Habits
Food Group Daily Weekly Monthly Never
Grains/Cereals
Vegetables
Fruits
Dairy
Eggs
Poultry
Meat (beef, pork, etc)
Seafood
Sugar/honey
Desserts
Juices
Other
Please describe what you typically eat for:
Breakfast:
Lunch:
Dinner:
Snack:
Do you eat between meals? Yes No
Do you eat your meals at regular times? Yes No
Which is your biggest meal? Breakfast Lunch Dinner
Rate your digestion. Good Fair Bad
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How much water do you drink per day?
None
5-6 glasses
1-2 glasses
7+ glasses
3-4 glasses
Indicate your eating habits.
Eat with my full attention on food
Watch television while eating
Converse a lot while eating
Rarely sit down to eat
Eat very quickly
Describe your diet.
Vegan
Kosher
Lacto-vegetarian
Other:
Lacto-ovo vegetarian
If you are a non-vegetarian, please indicate the proteins you eat.
Beef
Turkey
Other:
Pork
Seafood
Chicken
Eggs
Indicate which best describes your sense of taste (if any).
Loss of taste
Pungent taste in mouth
Sweet taste in mouth
Bitter taste in mouth
Sour taste in mouth
What taste(s) do you crave?
Sweet
Hot/spicy
Oily
Salty
Bitter
Sour
Starches
Are there particular foods that create discomfort when you eat them?
Sweet
Astringent
Salty
Bitter
Sour
Dairy products (including cheese)
Miscellaneous
Do you practice any type of meditation? Please explain.
Do you practice yoga? Which styles?
Which type of weather makes you feel most uncomfortable?
Cold Hot Cool and damp
Are you allergic to any substance?
Food
Other, please specify:
Pollen
Dust
Do you smoke cigarettes (or other substances)? Yes No
If yes, how many per day? 1/2 pack 1 pack 2 packs More than 2 packs
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How often do you drink alcohol?
Never
Several times a week
Less than once a week
Once a day
About once a week
More than once a day
How much at a time?
How often do you drink caffeinated beverages?
Never
4-5 cups daily
1 cup daily
2-3 cups daily
How would you rate your usual energy level?
Very high
Low
High
Very low
Moderate
Do you experience any of the following?
Depression
Loneliness
Anger
Lack of energy
Anxiety
Worry
Lack of memory
Suicidal thoughts or attempts
Fear or panic
High stress level
Light-headedness
Irritation
Social History
How are your family relationships?
Excellent
Poor
Good
Fair
How is your social life?
Excellent
Poor
Good
Fair
How is your mental health?
Excellent
Poor
Good
Fair
How is your career?
Love it
It’s unbearable
Like it
It’s bearable
How purposeful does your life feel?
Full satisfying
Empty
Somewhat satisfying
Neutral
Rate your spiritual life.
Fully satisfying
Empty
Somewhat satisfying
Neutral
As a child, did you experience any abuse or trauma? Yes No
Emotional
Verbal
Physical
Other, please specify:
Sexual
Page 8 of 11
For Men Only
Please indicate which of the following areas are troublesome (if any).
Hernias
Erection problems
Prostate problems
Testicular masses
Sexual difficulty
Libido
Discharge or sores
Urination
Fertility
Venereal disease
How would you rate your usual energy level?
Very high
Low
High
Very low
Moderate
Do you experience any of the following?
Depression
Loneliness
Anger
Lack of energy
Anxiety
Worry
Lack of memory
Suicidal thoughts or attempts
Fear or panic
High stress level
Light-headedness
Irritation
For Women Only
At what age did your menses begin?
Which of the following describes your menstruation?
Regular
Absent
Irregular
Ceased due to menopause
Too frequent
How many days does your menstrual period last?
1-4 days
Irregular throughout the month
5-7 days
Other:
More than 1 week
How is your menstrual flow?
Normal
Abnormal vaginal discharge
Heavy
Light
Do you have any associated symptoms (before or during menses)?
None
Migraine
Tension
Loneliness
Pain
Depression
Nightmares
Fluid retention
Acne
Frustration
Do you have any discharge outside of your menstrual period? Yes No
Do you ever experience pain during intercourse? Yes No
Are you pregnant now? Yes No
Do you have any sexual difficulties? Yes No
If yes, please explain.
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Do you take contraceptive pills or use other forms of birth control? Yes No
If yes, please explain.
Please list the number of previous pregnancies.
Do you have any history of abortion, miscarriage or problems related to pregnancy or labor? If yes,
explain.
How many children do you have?
How old are your children?
Do you do a breast self-exam regularly? Yes No
Do you experience any of the following?
Pain or tenderness
Other:
Lumps
Nipple discharge
I understand that this is an educational Ayurvedic consultation for the purpose of helping me improve my health and wellness. I understand this does not include medical diagnosis or treatment and is not a substitute for medical care of an agreement for ongoing care.
Patient Signature: Date:
Statement of Understanding I understand Jennifer Ward is a Certified Ayurvedic Practitioner and Educator who provides me
with information on the Ayurvedic approach to health care, which may affect my diet and health in a positive way.
I understand Jennifer Ward is not a medical doctor and does not seek to diagnose, treat, or prescribe for disease or other pathological conditions.
I agree I am interested in enhancing my own abilities to heal and establish health in mind and body, and this is the reason I have sought Ayurvedic consulting services.
I agree I may consult a licensed physician for any concern, at any time, about any disease or pathology that now exists or arises during my professional relationship with Jennifer Ward.\
Furthermore, I understand Jennifer Ward encourages regular medical check-ups from a licensed medical professional of my choice, and any medication I am now taking upon my licensed physician’s advice, or will take in the future, is taken strictly according to my licensed physician’s directions. Only a licensed physician of my choice can advise on medication dosages or the discontinuance or resumption of such medications.
My signature below acknowledges the above statements as fully read and understood.
Patient Signature: Date:
Page 10 of 11
Constitution (Prakriti) Evaluation
Circle one answer in each row, then add scores. Avoid the temptation to evaluate yourself based on how you would like to be rather than how you actually are. If in any category there have been great changes at various times in your life, please select “vata” as your answer even if the vata description in that category does not accurately describe you as you are today. If in any category you feel you belong partly to one constitution and partly to another, choose both. If in any category you feel you fit into all three constitutions, select the two best that characterize you. Whenever you have a significant doubt or confusion, select vata. While evaluating yourself keep in mind:
Vata is cold, dry, mobile and irregular
Pitta is hot, oily, sharp and irritable
Kapha is cold, wet, stable and soft. Prakriti evaluation, or body-typing, is neither a way to reinforce limitation nor a source of convenient labeling. It is a tool for self-examination and self-development for use in locating and settling into ones own niche in the cosmos.
Physical Makeup Vata Pitta Kapha
Body frame Thin and unusually tall
or short Medium body Stout, stocky or large /
broad body
Bones Light, small bones
and/or prominent joints Medium bone structure Heavy / dense bone
