Name
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First Name
Last Name
Email
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Phone
(###)
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Have you had an Ayurveda Consultation before?
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Date of Birth
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MM
DD
YYYY
Time of birth (if you know it)
Hour
Minute
Second
AM
PM
Where were you born?
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Why are you booking this appointment?
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Do you have anything specific you would like to discuss?
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What are your main concerns?
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Have you had any significant or persistent problems or diagnoses in the past? If so, please list them here, along with any current symptoms
Are you on any medication or supplements?
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Do you follow any specific diet?
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Describe how your digestion feels. (Ex: erratic, sluggish, fast, balanced, get very thirsty, etc.)
Do you have any allegies?
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How many bowel movements per day do you have?
Describe your bowel movements: ease, does it float or sink, any mucous, colour, any undigested food present.
Relationship status (married, single, in a relationship). If in a relationship, for how long and how is it going? Do you live together?
What is your occupation? Describe your work schedule/pattern. Are you happy with it?
How would you describe your personality?
What is the date of your last menstrual period?
How do you feel about the following areas of your life? Sex and Intimacy, Finances, Life purpose, Friendships, Family relationships, :
What do you do for relaxation and rest?
Do you feel ready to make change for the benefit of your health?
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Are you working with any other practitioners at the moment?
Would you be interested in any of the following?
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Have you sent your photos of tongue and full length body shot?
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please send to charlottegracehopson@gmail.com
