Ayurvedic Intake Form

Please note that our Ayurvedic Intake Form is HIPAA compliant to ensure privacy and confidentiality.

Please note that this form is HIPPA compliant to ensure privacy and confidentiality.

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Client Information

First Name(Required)

First

Last Name(Required)

Last

Email(Required)

Phone(Required)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Person filling out the form (if not the client)

First Last

Relationship to client

Spouse/Partner

Parent

Sibling

Friend

Other

Purpose of Consultation

What are you hoping to achieve with this consultation and work with Kreem Shakti?(Required)

Concern(Required)

Description of the main concern you would like to address

How severe is this concern?

Very severe, restricts my daily routine

Severe

Somewhat severe

Not severe, but some discomfort

Additional concerns you would like to address(Required)

Please select the number that best corresponds to your experience.
1 indicates the concern is not severe, but causes some discomfort.
5 indicates very severe, and restricts your daily routine.

Concern

Severity (1-5)

Emergency Contact Information

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Relation to you(Required)

Spouse/Partner

Parent

Sibling

Friend

Other

Background/Demographic Information

Date of Birth(Required)

Month

Day

Year

Age(Required)

Gender(Required)

Female

Male

Non-binary

Prefer not to say

Other

Height(Required)

Weight(Required)

Occupation(Required)

Marital Status(Required)

Single

Domestic Partnership

Married

Divorced

Widowed

Separated

Other

Ethnicity(Required)

Caucasian/White

African American/Black

Hispanic/Latino

Asian

American Indian/Alaskan Native

Pacific Islander/Hawaii Native

Mixed Race

Other

Which best describes your living situation?(Required)

Live alone

Live with partner/spouse

Live with family/relatives

Live with roommate(s)

Other

How did you hear about Kreem Shakti?(Required)

Online Search

Word of Mouth

Social Media

Event

Other

Personal Medical History

Please select all medical conditions you have experienced.

Alcoholism

Allergies

Alzheimer's

Anemia

Anorexia

Appendicitis

Arthritis

Asthma

Bleeding disorder

Blindness

Blood clots

Breast disease

Breast lump

Bronchitis

Bulimia

Cancer

Chemical dependency

Chicken pox

Chronic pain

COPD/Emphysema

Crohn's

Dementia

Diabetes Type I

Diabetes Type II

Emphysema

Endometriosis

Epilepsy

Fibroids

Glaucoma

Goiter

Gonorrhea

Gout

Hearing impairment

Heart attack

Heart disease

Heart problems

Hemorrhoids

Hepatitis A

Hepatitis B

Hepatitis C

Hernia

Herpes

High blood pressure/Hypertension

High cholesterol

HSV (Herpes)

Incontinence

Intersex condition

Irritable Bowel Syndrome

Kidney disease

Liver disease

Measles

Migraine headaches

Miscarriage

Mononucleosis

Multiple sclerosis

Mumps

Osteoporosis

Pacemaker

Pancreatitis

Pituitary Adenoma

Pnemonia

Polio

Polycystic Ovarian Syndrome (PCOS)

Prostate problems

Psychiatric care

Rheumatic fever

Scarlet fever

Sleep apnea

Stomach ulcers

Stroke

Suicide attempt

Thyroid problems

Tonsilitis

Traumatic brain injury

Tuberculosis

Typhoid fever

Urinary problems

Vaginal discharge

Vaginal disease

Other (please explain)

None of these

Additional conditions and information:

Please include specific information for any conditions you selected in the previous question.

Medical Condition

Do you feel this condition is managed well?

How long have you had this diagnosis

Who is your treating physician?

What type of treatment(s) have you received?

Mental Health History

Please select all mental health conditions you have.

ADD/ADHD

Alcoholism (sober or currently using)

Anxiety

Autism Spectrum Disorder

Bipolar I

Bipolar II

Depression

Eating Disorder

Obsessive Compulsive Disorder

PTSD

Schizoaffective Disorder

Substance Use Disorder (sober or currently using)

Other mental health conditions not listed

None the above

Additional conditions and information:

Please include specific information for any conditions you selected in the previous question.

Medical Condition

Do you feel this condition is managed well?

How long have you had this diagnosis

Who is your treating physician?

Reproductive History

Please indicate whether reproductive medical history is applicable to you.(Required)

Yes

Please select all that you have experienced.

Pregnancy

Given Birth

Had a Miscarriage

Had an Abortion

None of the above

Age of first Menses

Average duration of Menses Cycle

Date of last Menses

Month

Day

Year

Date of last PAP

Month

Day

Year

Are you currently using a form of birth control?

Yes

Surgical History

Have you undergone any surgeries or medical procedures?(Required)

Yes

Please list any surgeries or medical procedures you have undergone.

Surgery/Procedure Performed

Date of Surgery/Procedure:

State/Location of Surgery/Procedure

Hospitalizations

Other than for surgery or childbirth, have you ever been hospitalized overnight for a medical or mental health issue?(Required)

Yes

Please add additional information about your hospitalizations

Purpose of hospitalization

Date of hospitalization

Any procedures/treatments provided

Allergies

Please list all allergies you have.

Include all allergies to medications, foods, animals, and insects, as well as seasonal.

Allergy

Allergic Reaction

Medications

Please include any prescription, over the counter, vitamins, supplements, and herbs that you take (regularly and as needed)

Please list what medications you currently take.

Medication Name

Daily Dosage

What is it for?

How long have you been taking this?

Medical History of Blood Relatives

Please select if any of your blood relatives have had the following.(Required)

Alcoholism

Alzheimer’s Disease

Blood Clots

Breast Cancer

Cervical Cancer

Colon Cancer

Diabetes

Drug User

High Cholesterol

High Blood Pressure

Heart Attack

Heart Surgery

Mental health issues

Osteoporosis

Ovarian Cancer

Parkinson’s Disease

Prostate Cancer

Sickle Cell Anemia

Stroke

Thalassemia

Thyroid Condition

Not Listed

None the above

Add all of the checked conditions in the field below. You can add additional lines by clicking the + button on the right side.

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Blood Relative Medical History Count

Condition/Relation

Please be as specific as posible, including which side of your family the relative is.

Medical Condition

How is this person related to you?

Lifestyle Information

How many days per week do you engage in physical activities that result in sweating?(Required)

Please enter a number from 0 to 7.

Please list all physical activities you engage in.(Required)

Physical Activity

Average Time Duration

How many days per week do you watch TV or surf the internet?(Required)

Please enter a number from 0 to 7.

Do you watch TV, read, or surf the internet while eating meals?(Required)

Always

Often

Sometimes

Rarely

Never

How many hours of sleep do you get on average?(Required)

How do you connect with yourself?

Activity

How long do you spend doing this?

How many times per week do you do this?

In the past week, what has been your stress level?(Required)

Please select the number that best corresponds to your stress level, with 1 indicating no stress and 10 indicating the worst possible stress level.

Please enter a number from 1 to 10.

In the past week, what has been your energy level?(Required)

Please select the number that best corresponds to your stress level, with 1 indicating no energy and 10 indicating you feel fully energized.

Please enter a number from 1 to 10.

Are you often hungry at meal times?(Required)

Never

Rarely

Sometimes

Often

Always

Are your day to day meal times consistent?(Required)

Never

Rarely

Sometimes

Often

Always

Are you able to easily skip meals?(Required)

Never

Rarely

Sometimes

Often

Always

How often do you experience hunger throughout the day?(Required)

Never

Rarely

Sometimes

Often

Always

If your hunger is not gratified, do you feel uncomfortable or irritable?(Required)

Never

Rarely

Sometimes

Often

Always

How often do you feel full earlier than expected at the start of a meal?(Required)

Never

Rarely

Sometimes

Often

Always

How consistently is your food digested from day to day?(Required)

Never

Rarely

Sometimes

Often

Always

Please list any habits you partake in, and your level of use.

Alcohol, coffee, tea, tobacco, and marijuana are common habits.

Habit

Level of Use (light, moderate, heavy)

Personal Preferences

You may have more than 1 answer to the following questions. Please select the 1 that you feel is more dominant.

What type of weather do you prefer?(Required)

Warm

Cool

Which of these weather conditions is difficult for you to tolerate?(Required)

Hot

Cold

Humid

How often do you feel thirsty?(Required)

Often

Moderate

Rarely

How often do you sweat?(Required)

Often

Not that much, unless from physical activity

Rarely

Which of these explains your decision making?(Required)

I change my mind often

I can easily make a decision and stick to it

I prefer others to make decisions

What taste(s) do you prefer most?(Required)

Select all that apply.

Sweet

Salty

Sour

Bitter

Astringent

Review of Symptoms

Please check all symptoms you are experiencing or have experienced in the last 3 months.

General Symptoms(Required)

Appetite decreased

Appetite increased

Chills/Rigors

Cravings

Fatigue

Fevers

Increased/Easily induced sweating

Increased Thirst- craving cold beverages

Increased Thirst- craving hot beverages

Localized Weakness

More prone to bruising/bleeding

Night Sweats

Particular Tastes/Smells

Poor Sleep

Poor Balance

Sudden drop in energy

Tremors

Weight Gain

Weight Loss

Other symptom(s) not listed

None of these symptoms

Other symptom(s) not listed

What time of day do you experience a sudden drop in energy?(Required)

Please select the time(s) you most commonly experience this.

Skin and Hair Symptoms(Required)

Change in hair texture

Change in skin texture

Dandruff

Hives

Itching

Loss of hair

More prone to breakouts/pimples

Newly discovered moles

Rashes

Skin tags

None of these symptoms

Other symptom(s) not listed

Other Skin or Hair symptom(s) not listed

Head Symptoms(Required)

Dizziness

Facial Pain

Headaches

Migraines

Neck lumps/swelling

Other symptom(s) not listed

None of these symptoms

Other Head symptom(s) not listed

Eye Symptoms(Required)

Blurred vision

Cataracts

Color blindness

Double vision

Eye pain

Eye strain

Glasses

Night blindness

Poor vision

Spots in vision

Other symptom(s) not listed

None of these symptoms

Ear Symptoms

Ear aches

Poor hearing

Ringing in ears

Other symptom(s) not listed

None of these symptoms

Nose/Throat Symptoms(Required)

Nose bleeds

Sinus problems

Hayfever

Teeth or gum problems

Grinding teeth

Reocurring sore throat

Mouth sores

Jaw clicks

Allergies

Other symptom(s) not listed

None of these symptoms

Other eye, ear, nose, and throat symptom(s) not listed

Cardiovascular Symptoms(Required)

Blood clots

Chest pain

Cold extremeties

Difficulty breathing

Dizziness

Fainting

Irregular heartbeat

Low blood pressure

Swelling of feet

Venous swelling

Other Cardiovascular symptom(s) not listed

None of these symptoms

Other Cardiovascular symptom(s) not listed

Respiratory Symptoms(Required)

Asthma

Cough

Coughing blood

Difficulty lying down

Shortness of breath

Wheezing

Other respiratory symptom(s) not listed

None of these symptoms

Other Respiratory symptom(s) not listed

Musculoskeletal Symptoms(Required)

Neck pain, stiffness, or swelling

Back pain, stiffness, or swelling

Shoulder pain, stiffness, or swelling

Hand and/or wrist pain, stiffness, or swelling

Hip pain, stiffness, or swelling

Knee pain, stiffness, or swelling

Foot and/or ankle pain, stiffness, or swelling

Muscle weakness

Difficulty with balance

Difficulty with walking

Other Musculoskeletal symptom(s) not listed

None of these symptoms

Other Musculoskeletal symptom(s) not listed

Gastrointestinal Symptoms(Required)

Abdominal pain and/or cramps

Bad breath

Belching

Blood in stool

Chronic laxative use

Constipation

Diarrhea

Gas

Indigestion

Nausea

Vomitting

Other Gastrointestinal symptom(s) not listed

None of these symptoms

Other Gastrointestinal symptom(s) not listed

Genito-Urinary Symptoms(Required)

Blood in urine

Decrease in flow

Ecessive sexual urges

Frequent urination

Impotency

Painful urination

Kidney stones

Lack of bladder control

Urgency to urinate

Waking up from sleep to urinate

Other Genito-Urinary symptom(s) not listed

None of these symptoms

Other Genito-Urinary symptom(s) not listed

How many times per night do you wake up to urinate?(Required)

Neurological Symptoms(Required)

Anxiety

Areas of numbness

Concussion

Depression

Dizziness

Easily susceptible to stress

Irritability/bad temper

Lack of coordination

Loss of balance

Poor memory

Seizures

Treated for emotional problems

Other Neurological symptom(s) not listed

None of these symptoms

Other Neurological symptom(s) not listed

Pregnancy/Gynecology Symptoms

Breast lumps

Clots

Heavier periods

Hot flashes

Irregular periods

Lighter periods

Painful intercourse

Painful periods

Premenstrual symptoms

Vaginal discharge

Other Pregnancy/Gynecology symptom(s) not listed

None of these symptoms

Other Pregnancy/Gynecology symptom(s) not listed

Ayurvedic Intake Form

Client Information

Purpose of Consultation

Emergency Contact Information

Background/Demographic Information

Personal Medical History

Mental Health History

Reproductive History

Surgical History

Hospitalizations

Allergies

Medications

Medical History of Blood Relatives

Lifestyle Information

Personal Preferences

Review of Symptoms

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