Consultation Form

Date and time of appointment *

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Telephone Number(s) *

Email *

Place and Country of Birth

Date and Time of Birth (if known)

Gender *

Marital Status and number of children (if any)

Occupation

General Practitioner's Name

Name & Address of Health Centre

Current Medication History

Have you previously had an Ayurvedic consultation?

Yes
No

If yes, with whom and when?

Other Complementary and Alternative Therapies or Supplements

Medication Allergies

Present Complaint

History of Present Complaint

Past Medical / Surgical History

Social / Family History

Mental Condition

Blood Type (if known)

Weight (approximate)

Blood Pressure Measurements (if known)

What time do you usually turn out the light at night?

What time do you usually get up?

How is your sleep?

Easy to get off to sleep and sleep is pretty sound
Hard to get off to sleep
Often wake before 2 am
Often wake between 2 am and 6 am
Feel heavy and sluggish upon waking

Diet (copy)

Vegan (no dairy, eggs, meat or seafood)
Lacto-Vegetarian (includes dairy and perhaps eggs)
Mostly Vegetarian (occasionally eats meat or seafood)
Non-Vegetarian (frequently eats meat and/or seafood)

Appetite

Strong
Medium
Weak
Irregular (sometimes strong, sometimes medium, sometimes weak)

Meal Times

Regular
Irregular
Regular sometimes, other times not

Percentage of time you eat at home

Percentage: 0

Percentage of time you eat at work

Percentage: 0

Percentage of time you eat out

Percentage: 0

Do you snack between meals? If so, when and what type?

How many meals do you eat a day?

What time do you normally eat breakfast?

What time do you normally eat lunch?

What time do you normally eat supper?

When do you eat the largest meal of the day?

Breakfast
Lunch
Supper

What type of food tastes do you like the best?

What type of food tastes do you like the least?

How much fluid do you drink per day?

Do you eat the following?

Do you have any food intolerance or allergies?

Yes
No

If yes, what allergies or intolerances do you have?

Do you experience discomfort after eating?

Yes
Sometimes
Never

If yes, what symptoms do you experience?

Do you have problems with dairy?

Yes
Sometimes
Never

Do you have problems with wheat of gluten?

Yes
Sometimes
Never

Give examples of your typical breakfast

Give examples of your typical lunch

Give examples of your typical supper

Consumption of alcoholic drinks

Frequent
Moderate
Occasional or Never

Consumption of black tea, coffee, cocoa or other caffeinated drinks

Frequent
Moderate
Occasional or Never

Consumption of herbal teas or coffee substitutes

Frequent
Moderate
Occasional or Never

Consumption of fruit or vegetable drinks

Frequent
Moderate
Occasional or Never

Consumption or sugar or other sweeteners (includes sugary drinks)

Frequent
Moderate
Occasional or Never

Consumption of salads or raw foods

Frequent
Moderate
Occasional or Never

For women who are menstruating

At what age did Menstruation start?

Number of days per cycle

How is your menstrual flow?

Heavy
Medium
Light
Sporadic or Irregular

Do you produce clots during menstruation?

Yes
No
Sometimes

Do you experience PMT (Pre-Menstrual Tension)?

Yes
No
Sometimes

Do you experience painful periods (Dysmenorrhoea)?

Yes
No
Sometimes

For women who are experiencing or are beyond menopause

Are you going through menopause at the moment?

Yes
No

If you are you going through menopause, what are your symptoms?

If you are beyond the menopause, at what age did it cease?

If you are experiencing post-menopausal symptoms, please describe them.