AYURVEDIC TREATMENT FORM *First Name *Last Name *Email *Height/Weight *Marital status *Pregnancies (# and year) *Children *Menses Regular/Irregular *Occupation *Nature of daily work *Ability to concentrate *Stress level *Sleep quality *Sleep pattern *Addictions? *Appetite *Do you have regular motions? *Time/Type of breakfast *Time/Type of lunch *Time/Type of dinner *Time/Type of snacks *Beverages *Exercise done in the past *Nature of present exercise *Have you practiced yoga in the past? *Present physical complaints *Nature of complaints you are experiencing *How long have you had present complaints? *Modern Diagnosis *Treatments received *Current medications/supplements *Recommendations of your doctor *Past major illnesses/events *Past operations *Anything else helpful to mention
