Intake form for Ayurvedic Consultation: (please print and fill out as best as possible to save time in consultation) *Use Netscape or if using Internet Explorer be sure that 'View'-Text Size is set to medium Confidential Client History Client's full name ___________________________________________________ Address__________________________________________________________ City, State, Zip ____________________________________________________ Telephone numbers: Home________________Work________________________ Birth date ___________Birthplace ______________Birth time________________ e-mail ___________________ Marital status __________ # of children _________ Occupation________________________________________________________ Current Health History What are your current health concerns? (List in order of importance, frequency, intensity). __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Are you currently under the care of a medical Doctor or licensed health care professional? If so, whom? ____________________________________________ __________________________________________________________________ Have your current conditions been evaluated by your physician or licensed health care professional? Yes/No Is there any possibility that you might currently be pregnant? Yes/No Do you have allergic reactions to any substances? If yes, please list. __________________________________________________________________ Where do you hold stress in your body?___________________________________ Past Medical History Serious illnesses __________________________________________________ ________________________________________________________________ Hospitalizations ___________________________________________________ _________________________________________________________________ Operations_______________________________________________________ Have you seen or are you currently seeing a therapist or psychiatrist? Yes/No What doctors have you seen in the past year and for what reason?___________ ______________________________________________________________ If you are coming as the result of a specific condition, have you ever had this condition before? ___ If yes, when did it occur and what treatments did you receive? ___________________________________________________________________ ____________________________________________________________________

 

 

Family History Do you have a family history of: ___Cancer ___Heart disease ___ Stroke ___High blood pressure ___Diabetes ___Mental disease ___Other history of disease _____________________________________________________________ _____________________________________________________________ General Health Habits How many cups of caffeinated beverages do you drink per day? #_______________________ Types of beverages: coffee/tea/soda How many cups of uncaffeinated beverages do you drink per day? Type? _____________________________________________________________ #______________________________ How much water per day? Do you exercise regularly? Yes/No Length of time: ________ Times per week: ___________ Types of exercise: _________________________________________________________________ _________________________________________________________________ If you smoke, what amount per day? ____________________________________ Have you ever smoked? Yes/No Amount/day: ________ When quit: _________ If you drink alcohol, how many glasses do you drink per week? # ____________ Type(s): ___________________________________________ Any current or past problems with addiction or substance use? Yes/No Substance:__________________ Amount:___________ When quit: _________ Any current or past problems with chronic eating disorders or other food related issues? Yes/No Please explain: _____________________________________________________ __________________________________________________________________ Client's Signature: _____________________________ Date: ________________

 

 

 

Form B: Informed Consent 1. The goal of all programs is to create within your body and mind an optimum environment for healing to take place and to maximize your body's ability to heal itself using the principles of Ayurveda. 2. As a D.Ay and C.A.S., Freedom Tobias Cole is not trained in Western medical diagnosis or treatments. He is not a physician, nor a licensed health care professional, he is an Ayurvedic Practitioner using Ayurveda. 3. Freedom has trained at the New England Institute of Ayurvedic Medicine, the International Academy of Ayurveda, the California College of Ayurveda, and with the Sri Jagannath Center. 4. If you are suffering from a disease or severe symptom that has not been evaluated by a medical doctor or another licensed health care professional, you must be evaluated by a medical doctor. If you choose not to see a medical doctor, you will have to sign an acknowledgement that one was recommended to you. 5. An Ayurvedic practitioner may not alter your prescriptions without approval from your medical doctor. 6. If you decide to make your own formula (where herb quality, amount, and specificity is not monitored) instead of taking herbs given by the practitioner, even if recommended by the practitioner, then he holds no liability for those supplements. 7. I give permission for Freedom or his Ayurvedic colleagues to use the information in my chart for research purposes. (Any publication of our research will not include patient names). 8. There is a $100.00 charge for the initial consultation and $40.00 charge for each follow-up consultation. Special student rates are $80.00 for an initial consultation and $35.00 for follow-up visits. Fees for herbs must be paid in advance at the time they are ordered. Phone follow-ups are the same price as office visits. 9. Cancellations must be made within 48 hours, or a minimum of 50% of the consultation fee will be due. I have read and understand the above information. Client's signature: _________________________ Date: _____________

 

 

 

Form C: Current Medications, Herbs and/or Supplements What medicines, herbs, or supplements are you currently taking? Please include those that you have recently stopped taking also. 1. Name of Substance: _______________________________________ (Type: Prescription/ over the counter/ herbal/ vitamin/ other) Who recommended/prescribed it?_______________________________ Purpose of substance:________________________________________ How long have you been taking it: _______________________________ In what form do you take it (include dosage):_______________________ How often do you take it? At what times? _________________________ _________________________________________________________ What, if any, effects have you noticed? ___________________________ _________________________________________________________ 2. Name of Substance: _______________________________________ (Type: Prescription/ over the counter/ herbal/ vitamin/ other) Who recommended/prescribed it?_______________________________ Purpose of substance:________________________________________ How long have you been taking it: _______________________________ In what form do you take it (include dosage):_______________________ How often do you take it? At what times? _________________________ _________________________________________________________ What, if any, effects have you noticed? ___________________________ _________________________________________________________ 3. Name of Substance: _______________________________________ (Type: Prescription/ over the counter/ herbal/ vitamin/ other) Who recommended/prescribed it?_______________________________ Purpose of substance:________________________________________ How long have you been taking it: _______________________________ In what form do you take it (include dosage):_______________________ How often do you take it? At what times? _________________________ _________________________________________________________ What, if any, effects have you noticed? ___________________________ _________________________________________________________

4.Name of Substance: _______________________________________ (Type: Prescription/ over the counter/ herbal/ vitamin/ other) Who recommended/prescribed it?_______________________________ Purpose of substance:________________________________________ How long have you been taking it: _______________________________ In what form do you take it (include dosage):_______________________ How often do you take it? At what times? _________________________ _________________________________________________________ What, if any, effects have you noticed? ___________________________ _________________________________________________________ 5. Name of Substance: _______________________________________ (Type: Prescription/ over the counter/ herbal/ vitamin/ other) Who recommended/prescribed it?_______________________________ Purpose of substance:________________________________________ How long have you been taking it: _______________________________ In what form do you take it (include dosage):_______________________ How often do you take it? At what times? _________________________ _________________________________________________________ What, if any, effects have you noticed? ___________________________ _________________________________________________________ 6. Name of Substance: _______________________________________ (Type: Prescription/ over the counter/ herbal/ vitamin/ other) Who recommended/prescribed it?_______________________________ Purpose of substance:________________________________________ How long have you been taking it: _______________________________ In what form do you take it (include dosage):_______________________ How often do you take it? At what times? _________________________ _________________________________________________________ What, if any, effects have you noticed? ___________________________ _________________________________________________________ 7. Name of Substance: _______________________________________ (Type: Prescription/ over the counter/ herbal/ vitamin/ other) Who recommended/prescribed it?_______________________________ Purpose of substance:________________________________________ How long have you been taking it: _______________________________ In what form do you take it (include dosage):_______________________ How often do you take it? At what times? _________________________ _________________________________________________________ What, if any, effects have you noticed? ___________________________ _________________________________________________________

 

Form F: Routine Form Please describe your average activities from the time you wake up until the time you go to sleep. (Eating, sleeping, exercise, work, and activities). _______ :____________________________________________________________ 6:00 AM: ____________________________________________________________ 6:30 AM: ____________________________________________________________ 7:00 AM: ____________________________________________________________ 7:30 AM: ____________________________________________________________ 8:00 AM: ____________________________________________________________ 8:30 AM: ____________________________________________________________ 9:00 AM: ____________________________________________________________ 9:30 AM: ____________________________________________________________ 10:00 AM: ___________________________________________________________ 10:30 AM: ___________________________________________________________ 11:00 AM: ___________________________________________________________ 11:30 AM: ___________________________________________________________ 12 Noon: ____________________________________________________________ 12:30 PM: ___________________________________________________________ 1:00 PM: ____________________________________________________________ 1:30 PM: ____________________________________________________________ 2:00 PM: ____________________________________________________________ 2:30 PM: ____________________________________________________________ 3:00 PM: ____________________________________________________________ 3:30 PM: ____________________________________________________________ 4:00 PM: ____________________________________________________________ 4:30 PM: ____________________________________________________________ 5:00 PM: ____________________________________________________________ 5:30 PM: ____________________________________________________________ 6:00 PM: ____________________________________________________________ 6:30 PM: ____________________________________________________________ 7:00 PM: ____________________________________________________________ 7:30 PM: ____________________________________________________________ 8:00 PM: ____________________________________________________________ 8:30 PM: ____________________________________________________________ 9:00 PM: ____________________________________________________________ 9:30 PM: ____________________________________________________________ 10:00 PM: ___________________________________________________________ 10:30 PM: ___________________________________________________________ 11:00 PM: ___________________________________________________________ 11:30 PM: ___________________________________________________________ 12:00 Midnight: _______________________________________________________ ________: ___________________________________________________________ ________: ___________________________________________________________

Any regular practices that haven't been included in the above routine? Exercise/ Meditation/ Spiritual practices? _______________________________________ _______________________________________________________________ _______________________________________________________________ Are you sexually active? ___________ Frequency? ________________________ Other information: ____________________________________________________ Regular diet? What type of food(s) are eaten on a regular basis? Any routines around food?________________________________________________________ Breakfast: _________________________________________________________ __________________________________________________________________ Lunch:____________________________________________________________ __________________________________________________________________ __________________________________________________________________ Dinner: ___________________________________________________________ __________________________________________________________________ __________________________________________________________________ Snacks:_____________________________________________________________ _________________________________________________________________

 

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