Pre-Consultation Form Name * First Name Last Name Email * Phone (###) ### #### Have you had an Ayurveda Consultation before? * Yes No Unsure Date of Birth * MM DD YYYY Where were you born? * Why are you booking this appointment? * I have an existing health concern I would like to know my mind-body type I would like to assess if I have any current imbalances I am keen to learn more about how I can support myself General interest in ayurveda I would like to improve my diet Not sure Do you have anything specific you would like to discuss? * What are your main concerns? * Skincare, skin issues Digestion, gut health Mental Health, mood, emotional health Sleep Energy levels Hormonal health, fertility, peri/menopause Seasonal Living Nutrition and food General Health Physical Fitness Disease prevention Help with a specific medical condition 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? * Do you follow any specific diet? * Describe how your digestion feels. (Ex: erratic, sluggish, fast, balanced, get very thirsty, etc.) Do you have any allegies? * 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? * Absolutely yes, I will do anything I am prepared to make changes, though need to take it slowly I'll give it a go, but I have a lot on Not sure, my intentions are good, but I find it hard to commit I don't know, depends on what they are I don't really want to make changes I won't make any changes right now I am ju intrigued to hear what you say. Are you working with any other practitioners at the moment? Would you be interested in any of the following? * Guided mind/ body resest Cleanse programme Retreats Online Subscription with tailored recipes, home remedies, mini lectures, journalling prompts, movement + mindful practices 1:1 meditation + yoga nidra Online Deep Rest Group sessions Thank you for filling out this pre-consultation form. There is nothing else to do now until your session. Any questions please get in touch!
