Saraswati Om | Health History Intake

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Please note that Ayurvedic Consultations do not include medical diagnosis and treatments.

If you are concerned about a medical condition or a latent or potential medical condition you should see a medical doctor.

Contact Information

Name *

First

Last

Date / Time

Date

Time

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Mobile Phone

Email *

PERSONAL INFORMATION

Date of Birth

Date

Time

Please include the full year and a.m. and p.m. at the time of birth if known.

Place of Birth: City

State/Region

Country

Age

Sex

Occupation

Marital Status

Referred By

Family Physician

Family Physician, PCP (Primary Care Physician), Name + Practice Name

Practice Address

Address Line 1

Address Line 2

City

State

Zip Code

Are you currently under a physician’s care for a specific medical problem? If yes, for what and for how long?

If yes, for what and for how long?

Please tell us your present concerns and/or conditions. How long have they troubled you?

What would you like to achieve or change in terms of your health and wellness?*

History of Smoking: (what, how often, how much, how many years)

Drinking Alcohol: (what, how often, how much, how many years)

Recreational/Non-prescription Drugs: (what, how often, how much, how many years)

What surgeries have you had? (Include dates)

Last physical examination:

Blood Pressure

Cholesterol

Height in Inches

Please enter your height in inches.

Weight

Weight Changes?

If yes, please describe.

What known allergies do you have?

MEDICATIONS +/or SUPPLEMENTS

What prescription drugs or medications are you currently taking or have taken within the last 6 months?

There is an “ADD” selection under fields to add more medications/supplements.

Medication

More Information

Reason, duration taken, current dosage quantity, frequency per day and time taken: before/after/during or between meals.

Attach additional sheet(s) if necessary.

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

PERSONAL HISTORY

Do you or your family members have a history of the following? (Please check boxes all that apply)

Allergies to Food

Myself
Maternal
Paternal

Allergies to Drugs

Myself
Maternal
Paternal

Dental Treatment Complications

Myself
Maternal
Paternal

Bleeding Gums

Myself
Maternal
Paternal

Contact Lenses

Myself
Maternal
Paternal

Glaucoma

Myself
Maternal
Paternal

Eye Surgery

Myself
Maternal
Paternal

Pain in the Ear

Myself
Maternal
Paternal

Ringing in the Ear

Myself
Maternal
Paternal

Shortness of Breath

Myself
Maternal
Paternal

Asthma

Myself
Maternal
Paternal

Pneumonia

Myself
Maternal
Paternal

Myself
Maternal
Paternal

High Blood Pressure

Myself
Maternal
Paternal

Low Blood Pressure

Myself
Maternal
Paternal

Dizziness

Myself
Maternal
Paternal

Fainting

Myself
Maternal
Paternal

Seizures

Myself
Maternal
Paternal

Convulsions

Myself
Maternal
Paternal

Epilepsy

Myself
Maternal
Paternal

Diabetes

Myself
Maternal
Paternal

Feet or Ankles Swelling

Myself
Maternal
Paternal

Chest Pain

Myself
Maternal
Paternal

Angina

Myself
Maternal
Paternal

Heart Murmur

Myself
Maternal
Paternal

Heart Attack

Myself
Maternal
Paternal

Heart Disease

Myself
Maternal
Paternal

Heart Surgery

Myself
Maternal
Paternal

Rheumatic Fever

Myself
Maternal
Paternal

Stroke

Myself
Maternal
Paternal

Cerebrovascular Accident

Myself
Maternal
Paternal

Cancer

Myself
Maternal
Paternal

Chemotherapy

Myself
Maternal
Paternal

Radiation Treatment

Myself
Maternal
Paternal

Hepatitis A

Myself
Maternal
Paternal

Hepatitis B

Myself
Maternal
Paternal

Mononucleosis

Myself
Maternal
Paternal

Jaundice

Myself
Maternal
Paternal

Anemia

Myself
Maternal
Paternal

Gallstone

Myself
Maternal
Paternal

much, not any

Kidney Disease

Myself
Maternal
Paternal

Kidney Stones

Myself
Maternal
Paternal

Bladder Disease

Myself
Maternal
Paternal

Thyroid Condition

Myself
Maternal
Paternal

Thyroid Medication

Myself
Maternal
Paternal

Ulcers

Myself
Maternal
Paternal

Intestinal Bleeding

Myself
Maternal
Paternal

Chronic Constipation

Myself
Maternal
Paternal

Recurring Diarrhea

Myself
Maternal
Paternal

Arthritis

Myself
Maternal
Paternal

Implant

Myself
Maternal
Paternal

Prosthesis

Myself
Maternal
Paternal

Prolonged Bleeding If Cut

Myself
Maternal
Paternal

Psychiatric Treatment

Myself
Maternal
Paternal

Venereal Diseases (STDs)

Myself
Maternal
Paternal

HIV Exposure

Myself
Maternal
Paternal

Sleep Disorders

Myself
Maternal
Paternal

Any other family illnesses not listed?

History of Any Other Disease or Problems?

Please list any other personal illnesses, surgeries, diseases, injuries, trauma, emotional stresses, mental stresses, life-style conditions, addictions, alcohol, drug abuse, changes of weight, known allergies, or anything else to help us clearly understand your healthcondition:

EXERCISE

Do you currently engage in any exercise or physical activity? If so, what type(s)?

Have you ever done Yoga postures before? If so, what type(s), how often?

MENSES *if applicable

Age of onset of menses

Are you currently pregnant?

If yes, How many weeks?

Difficult past pregnancies?

Number of previous pregnancies:

Complications?

If so, what type(s)?

Do you use Birth Control?

How long?

Date of Last Menstrual Period:

Cycles

Regular
Irregular

Color of Blood

Flow

Heavy
Medium
Light

Pain and/or difficulty during cycle?

Length of cycle

Days between cycles:

Clots

If yes, when?

Please describe:

Please List PMS Symptoms:

Any other symptoms during cycle:

Yeast infections?

Urinary tract infection (UTI) (frequency, duration):

Menopausal stage / symptoms

Other Information:

PROSTATE * if applicable

Prostate Condition?

Other Information:

Check All That Apply To You Currently And Within The Last Six (6) Months:

Digestion

Irregular with
Bloating
Gas/Flatulence
Abdominal Discomfort
Gurgling Intestines
Breathlessness
Quick digestion with
Acid Indigestion
Heartburn
Burning Pain
Still hungry after eating
Nausea
Vomiting
Slow digestion with
Feeling of heaviness
Lethargy
Sleepy after eating
Low energy after meals
Excess mucous secretions

Appetite

Irregular
Sometimes eats at midnight
Excess hunger
Sharp hunger
Desire to eat large amounts of food
Desire to eat large amounts of food
Feels hypoglycemic
Emotional eating (No urge for food but still eats)
Dull / No appetite

Cravings

Fried food
Hot spicy food
Meat or other protein
Sweets
Cooling foods & drinks
Hot, sharp, dry & spicy food
Wine or alcohol

Elimination

Tendency toward constipation
Dry
Irregular
Defecates without satisfaction
Passes gas during elimination
Loose stools
Diarrhea
Mucous in stool

Pain

Shifting
Tearing
Moving
Vague
Throbbing
Colicky
Cutting
Excruciating with breathlessness, fear and tachycardia
Burning
Sharp
Hot
Migraine headaches
Sucking pain with fever, nausea and irritability
Intense pain
Dull
Stable
Deep dull aching pain
Can sleep through the pain

Skin

Dry
Cracked
Rough
Thin
Discolored
Patchy
Hives
Rash
Urticaria
Acne
Tender
Warm/hot to touch
Redness
Boils
Ruddy
Excess oily
Thick
Pallor
Cold/clammy
Lustrous
Itchy

Sweating

Scanty or no sweat
Excess
Profuse with body odor
Cold/clammy

Sleep

Insomnia
Need night light
Restless
Difficulty falling asleep
Interrupted sleep
Must have complete darkness
Needs to read/TV to sleep
Excess sleep
Daytime napping
Heavy sleeper
Slow to awaken
Hypersomnia

Seasonal Allergies

Breathlessness
Wheezing
Constricted Breathing
Rash
Itching eyes
Hives
Irritation
Inflammation
Runny nose
Watery eyes
Congestion

Food Sensitivity

Night shades
Leftovers
Dry fruits
Raw food
Hot spicy foods
Sour foods
Fermented foods
Dairy products

Muscle Reactivity

Twitching
Cramping
Weakness
Numbness
Tingling
Spasms
Bruising
Tenderness to touch
Sore
Excess heat
Tumors
Cysts
Growths
Generalized weakness

Bone and Joints

Painful
Popping
Cracking
Numbness
Stiffness
Loose
Osteopenia
Osteoporosis
Medical fractures
Scoliosis
Inflamed
Hot / feverish
Tender
Inflammatory arthritis
Osteomyelitis
Bursitis
Swollen joints
Bone tumors
Bone spurs
Osteosarcoma
Non-inflammation with profuse infusion
Sclerosis

Circulation

Cold extremities (hands, feet)
Burning hands / feet
Bruises easily
Tendency toward bleeding
Cold clammy hands
Varicose veins
Thrombotic element

General Symptomatology

Dry cough
Ringing ears
Light-headed
Dryness: external/internal
Hemorrhoid: External/ non- bleeding
Low back ache
Irregular metabolism
Dry mouth
Receding gums
Blackish brownish discoloration
Fatigue
Lack of power, tone & strength
Paralysis
Slipped disc
Hernia
Difficulty sweating
Cold extremities (hands, feet)
Spontaneous bleeding
Hyper-sensitive to smells
Hair loss
Excess thirst
Hemorrhoid: Internal/bleeding
Hot flashes
Tendency toward inflammatory conditions
Acidic saliva
Hyper acidity
Yellowish discoloration
Fainting
High metabolism
Cold
Cough
Congestion
Excess urination
Frequent urination
Fibrocystic
Over salivation
Edema
Slow metabolism
Albuminuria
Lipoma(s)
Cataracts

Nature of response within relationships

Talkative
Uncertain
Anxious
Lonely
Insecure
Excitable
Shy
Spacey
Seeks power, prestige and position
Perfectionist
Competitive
Seeker of knowledge
Based on acquiring comfort and pleasure

Other (Not Listed Above)