Via Vedica PO Box 138 Culver City, CA 90232
Ayurvedic Intake Form
Name: _______________________________________Today’s Date_________________
Date of birth: _______________________Time of birth: ____________________________
Place of birth: _____________________________________________________________
Place of childhood:_________________________________________________________
Other Places lived: _________________________________________________________
Current address: __________________________________________________________
Home phone: __________________________________ Work phone: ________________
Email address: ____________________________________________________________
Occupation: ______________________________________________________________
Age: _________ Sex: ____________ Height: _________________ Weight: ____________
Living situation: ___Spouse ___Partner ___Alone ___Friends ___Parents ___Children
Emergency contact: ______________________________ Phone: ___________________
_____Spouse _____Parent _____Friend _____Other (specify)_____________________
Main health concerns and intentions: ___________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Origins, duration and progress of the symptoms of main concerns: ___________________
________________________________________________________________________
________________________________________________________________________
Past treatments : __________________________________________________________
________________________________________________________________________
Marina Baroni, Dipl. Ayu. 310 433-3196 [email protected]
Via Vedica PO Box 138 Culver City, CA 90232
Please check any recent or chronic concern:
Respiratory
Cardiovascular
Gastro-Intestinal
__congestion
__high blood pressure
__constipation
__dry cough
__low blood pressure
__diarrhea
__allergy
__poor circulation
__indigestion
__asthma
__pain in the heart
__gas
__chronic cough
__stroke
__bloating
__wheezing
__nausea
__sinus infection
__vomiting
__sore throat
__ulcers
__blood in stools
Skin
Muscles/Joints
Urinary/Kidneys
__dry skin
__muscle twitching
__excessive urination
__acne
__muscle weakness
__kidney stones
__skin rashes, hives
__muscle cramping
__water retention/edema
__bruises
__joint stiffness
__painful urination
__joint swelling
__blood in urine
__muscle/joint pain,
inflammation
General
__low energy
__anxiety, nervousness
__excessive appetite
__fatigue
__low appetite
__depression, lethargy
__insomnia
__stress
__anger
Marina Baroni, Dipl. Ayu. 310 433-3196 [email protected]
Via Vedica PO Box 138 Culver City, CA 90232
Reproductive Female
__Age of first cycle
__heavy bleeding
__pain with menses
__length of cycle
__bleeding between periods
__bloating before menses
__pms
__blood clots
__irregular periods
__painful intercourse
__breast lumps
__breast pain
__vaginal discharge
__vaginal dryness
__hot flashes
__mood swings
__infertility
__vaginal itching
__ovarian cysts
__fibroids
__abnormal PAP smear
__cancer
__hysterectomy
__endometriosis
Birth control method:
___________________________________________________________________________
Have you ever been on a birth control pill?
If yes, what kind?
___________________________________________________________________________
Please list pregnancies, miscarriages and abortions you have had:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Reproductive Male
__burning/discharge
__painful testicles
__vasectomy
__lumps/swelling of testicles
__infertility
Marina Baroni, Dipl. Ayu. 310 433-3196 [email protected]
Via Vedica PO Box 138 Culver City, CA 90232
Are you currently seeing any health care providers?
____Yes
____No
If yes, please list their names and the reasons you are seeing them:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Are you familiar with Ayurveda? ______________________________________________
________________________________________________________________________
Please list any dietary supplements, vitamins, herbs you are currently taking:
Name
Reason
Quantity
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please list any medications you are currently taking:
Name
Reason
Quantity
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Marina Baroni, Dipl. Ayu. 310 433-3196 [email protected]
Via Vedica PO Box 138 Culver City, CA 90232
Health History
Please list any medications, herbs, foods you are allergic to:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please list any previous serious conditions including operations:
Condition
Year
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please list all serious health conditions in your family and your relation to that person:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Marina Baroni, Dipl. Ayu. 310 433-3196 [email protected]
Via Vedica PO Box 138 Culver City, CA 90232
Diet and Lifestyle
How is your appetite?
___________________________________________________________________________
Diet: ____vegetarian
____non-vegetarian
____other (please explain) _____________________________________________________
___________________________________________________________________________
Please describe your meals including times of the day and food choices:
Breakfast:___________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Lunch: _____________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Dinner: _____________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Snacks: ____________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Liquid intake, in cups:
___caffeinated beverages
___juice ___water/herbal teas ___dairy
___other
Marina Baroni, Dipl. Ayu. 310 433-3196 [email protected]
Via Vedica PO Box 138 Culver City, CA 90232
Do you have any food cravings?
___________________________________________________________________________
___________________________________________________________________________
Do you have any addictions?
___smoking
___drugs ___alcohol
Bowel habits: ______________________________ Urinary habits: _____________________
Sleep habits: ________________________________________________________________
Stress level: _________________________________________________________________
Exercise routine: _____________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
According to Ayurveda the frequency of sexual activity may have an impact on health.
Please indicate how often you engage in sexual activity:
____daily
___ several times a week
____several times a month ____occasionally
____never
Please describe your daily routine/activities:
Morning: ___________________________________________________________________
___________________________________________________________________________
Day: _______________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Evening/Night: _______________________________________________________________
___________________________________________________________________________
Marina Baroni, Dipl. Ayu. 310 433-3196 [email protected]