Name:
Gender:
Male
Female
Date of birth:
Time of birth:
Place of birth:
Age:
Daytime phone:
Phone number:
Mobile:
Email:
Address:
Occupation:
Marital status:
Number of children with their
age :
Height in cms/feet & inches
:
Weight in stone/kilos :
Time period you can
stay in an Ayurvedic retreat (give
dates if possible) :
Main aim in visiting an Ayurvedic
retreat:
Maximum price per day (includes
food, treatment, accommodation):
Visiting alone or with company:
Detail previous visits to
India or an Ayurvedic centre:
Diagnosed conditions if any:
Present health concerns
and symptoms:
Present medications and treatments
if any:
Present health supplements
if any:
Past surgeries (include terminations
for women):
Hospitalisations you have
had:
Accidents you have had:
Other major past illnesses:
Previous long term medication:
Previous healing systems tried:
Detail mental or physical
conditions your mother/ father/ grandparents/ sisters/ brothers
suffer/ suffered from:
Food items you are allergic
to and reaction:
Food items you avoid and why:
Food cravings:
Recreational drug use (include
alcohol, cigarettes):
The season/s you prefer:
The weather in which you feel
really uncomfortable:
The time of the day you are
energetic and positive:
The time of the day you are
tired:
Are you vegan/vegetarian/non-vegetarian:
Vegan
Vegetarian
Non-Vegetarian
Appetite:
Variable
Regular
Irregular
Low
Do you feel hungry:
Never
Rarely
Occassionally
Frequently
Always
If food is delayed / missed
- do you get a headache /stomach cramps / cloudy thinking
/ agitated /spaced out / acidic reflex / burning sensation
in tummy / weakness / nausea / lighter / energetic:
After eating do you feel:
Refreshed
Light
Relaxed
Tired
Sleepy
Low energy
Do you usually / occasionally
/ frequently get bloating / gas / cramps after eating / when
you don't eat properly / even when you eat properly:
Other important symptoms
you have noticed related to your digestion are:
Do you clear your bowels
pass:
Once
Twice
Thrice
a day
Do your stools sometimes
/ usually - float / sink and are formed / unformed:
Float
Sink and are formed
Unformed
Do you sometimes / occasionally
/ get /blood / mucus / undigested food in your stool:
Are you prone to diarrhea
/constipation whenever there is an emotional stress or when
you eat unsuitable foods:
Number of times you urinate
per day and night:
Is your urine yellow
/brownish / reddish/ often or occasionally:
Is your sleep generally:
Fine
Deep
Shallow
Disturbed
Your usual bed time:
Do you feel:
Refreshed
Tired
Extremely Tired
in the morning when you wake up
Do you sweat:
Profusely
Easily
Rarely
Always
Never
Frequently
Do you exercise regularly
/ rarely / occasionally / frequently for so many hours a week:
Spiritual practices you
observe regularly:
Is your energy level
good in the morning /midmorning /afternoon /evening:
Morning
Mid-morning
Afternoon
Evening
Slowly I am:
Getting better
Symptoms
are progressively worsening
Sometimes
worse sometimes okay
Sometimes I am okay
Problems with other systems
such as the following: Neuromuscular,
Libido/sexuality, Emotions, Weight,
Hair, Skin, Pain anywhere,
Gas:
Do you tend to get any
of the following:
Any other important information
regarding your health:
Use this section only if you
are female.
Have you had caesarians?
Yes
No
Are your menstrual periods
regular?
Yes
No
Do you get PMT?
Yes
No
Do you get clots?
Yes
No
Do you get cramps?
Yes
No
Do you get extreme fatigue?
Yes
No
Details of miscarriages:
If you have been trying
to fall pregnant, for how long?
