Ayurvedic Health & Wellness – Initial Client Questionnaire – Moksha Holistic Center – Fresno, California

Ayurvedic Health & Wellness
Initial Client Questionnaire

- Step 1 of 14

Personal Details:

Name *

First

Middle

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone (cell) *

Phone (work)

Phone (home)

Fax

Gender *

Male
Female
Non-Binary

Age

Date of Birth *

Marital Status *

Single
Married
Divorced
Widowed

Occupation *

What are your goals for your wellness consultation today? *

Medical History

(Type 'none' if a question does not apply to you.)

Are you Allergic to, or intolerant of, any Herbs, Spices, Foods or Drugs? Please list below: *

Do you currently engage in any activities that could compromise your health or would be considered “unhealthy”? *

Do you have any current health concerns or problems? *

Any significant previous health concerns or problems? *

Any significant family history of health problems? *

Please list all prescription medications, birth control pills, hormone replacement therapy, vitamins or other supplements that you are taking: *

Please list foods you typically eat for:

Breakfast *

Lunch *

Dinner *

Snacks *

Previous Ayurvedic evaluations and treatments:

List date and place of most recent previous Ayurvedic evaluation, if any: *

List date and place of most recent in-residence Ayurvedic programs, if any: *

Body Measurements

Height (ft.) *

(in.) *

Weight in lbs (now): *

(1 year ago):

Maximum (when)

Minimum (when)

Any weight gain or loss in the past 6 months? (# of pounds, + or -)

Digestion:

1. Is your digestion: *

Good
Fair
Poor

2. Is your appetite: *

Strong
Moderate
Mild
Variable

3. In general, how is your energy during the day? *

Strong
Medium
Low
Variable

4. Do you often feel heavy after eating? *

5. Do you often feel sleepy after eating? *

6. Do you have problems with *

Gas
Flatulence
Belching
Bloating
Heartburn
Acid
Indigestion
Reflux
Other

Other (please explain): *

7. Are there any foods that cause discomfort? *

Elimination:

1. Do your bowel movements tend to be? *

Regular
Irregular

2. How often do you have bowel movements? *

More than 3 times a day
2-3 times per day
Once daily
Less than once every 3 days

3. When do you usually have bowel movements? *

First thing in the morning
Later in the morning
In the afternoon
Immediately after meals
At night after dinner

4. Stools are usually: *

Soft
Medium
Hard
Variable consistency

5. Do you use enemas or laxatives? *

How often? *

6. Do you have hemorrhoids? *

If yes, do they bleed? *

Diet and Eating Behavior:

(Type 'none' if a question does not apply to you.)

1. Is your diet: *

Non-Vegetarian
Mostly Vegetarian
Vegetarian

2. Which is your main meal? *

Breakfast
Lunch
Dinner

3. Do you eat between meals? *

4. How much time (in minutes) do you take for: *

5. Do you sit for 5-10 minutes after finishing a meal? *

6. Do you feel you now have or had in the past an eating disorder? *

7. How often do you eat the following?

a. Leftovers? *

Often
Sometimes
Rarely
Almost never

b. Frozen foods? *

Often
Sometimes
Rarely
Almost never

c. Packaged/processed foods? *

Often
Sometimes
Rarely
Almost never

d. Cold foods and/or drinks? *

Often
Sometimes
Rarely
Almost never

e. Raw vegetables (salad)? *

Often
Sometimes
Rarely
Almost never

f. Red meat? *

Often
Sometimes
Rarely
Almost never

g. Spicy foods? *

Often
Sometimes
Rarely
Almost never

8. How many times per week do you eat out in a restaurant? *

9. How often do you microwave your food or drinks? *

Often
Sometimes
Rarely
Almost never

10. About what percentage of your food is organically grown? *

11. How many soft drinks or diet soft drinks do you drink each week? *

12. What kind of water do you drink? *

Sleep:

(Type 'none' if a question does not apply to you.)

1. Is your sleep disturbed? *

Not at all
Somewhat
Moderately
Severely
Very Severely

2. Do you take sleep aids? (If yes, what kind) *

3. What time do you usually go to bed (lights out)? *

4. What time do you usually wake up? *

5. Are your bedtime and arising times regular from day to day? *

Very Regular
Mostly Regular
Somewhat Regular
Mostly Irregular

Daily Routine:

(Type 'none' if a question does not apply to you.)

1. How regular is your daily routine (for example, do you go to bed, get up, and eat your meals around the same time daily)? *

Very Regular
Mostly Regular
Somewhat Regular
Mostly Irregular

2. Do you go to bed early (by 10:00-10:30 p.m.)? *

3. Do you get up early (by 6:00-6:30 a.m.)? *

4. Do you eat your meals on time? *

5. How often do you exercise? *

Regularly
Occasionally
Never

6. What type of exercise do you do, if any?

7. Is your exercise? *

Vigorous
Moderate
Light
None

8. Do you practice meditation? *

a. How often? *

Regularly
Occasionally
Never

b. What kind?

9. Do you take daytime naps? *

Often
Sometimes
Rarely
Almost never

10. Do you travel a lot? *

11. How often do you:

a. Smoke: *

b. Drink alcohol: *

c. Drink caffeinated beverages: *

12. Do you feel you take enough time for yourself? *

13. How many hours per day do you use a computer? *

14. How many minutes per day on a cell phone? *

15. Are you having work or family problems that are impacting your health? *

16. Do you perform “cleansings”? *

Describe:

Psychology

(Type 'none' if a question does not apply to you.)

1. How would you describe your mood? *

2. Do you suffer from? (select relevant) *

Anxiety
Depression
Anger
Mood Swings

3. Are you currently in psychological counseling? *

Environment

1. What direction does your house face? *

2. What side of the house do you enter? *

3. What direction does your head of your bed point towards? *

4. Do you live near a power plant or high tension wires? *

5. Are you exposed to chemicals, pesticides or other toxins on a regular basis? *

6. Have you recently painted or renovated your home or office? *

Section for Women:

(Type 'none' if a question does not apply to you.)

Menstrual History: Age of onset (in yrs) *

Date of last period:

Date of last GYN exam:

Any abnormalities? *

If yes, describe:

Do you take birth control pills? *

Length of time taking: (years, months)

1. Which of the following describes your menstruation? *

Regular
Absent
Irregular
Too frequent
Infrequent
Ceased due to menopause

2. How many days does your menstrual period last?

Zero to four days
Five to seven days
More than seven days
Spotty/Irregular

(If you are post-menopause, please skip to Question 5)

3. Is your menstrual flow?

Heavy
Light
Normal

(If you are post-menopause, please skip to Question 5)

4. Associated symptoms (before or during Menstruation):

None
Fluid retention
Pain
Acne
Other

(If you are post-menopause, please skip to Question 5)

Please describe other symptoms:

5. Do you have any discharge outside of your menstrual period? *

6. Do you have any itching of vaginal area? *

7. Pregnancies:

Are you pregnant now? *

Yes
No
Don't Know

Number of children: *

Number of pregnancies: *

Describe any complications with pregnancy:

Digestion Assessment By Dosha Predominance

Is your hunger *

Irregular, varies from meal to meal.
Generally strong; cannot skip meals.
Mild; can generally easily skip meals.

After eating, speed of digestion (time it takes to feel hungry again) is *

Irregular, varies from meal to meal.
Quick: I feel hungry again after only a couple of hours.
Slow: I'm not hungry again for 5-6 hours.

Food capacity (amount you can eat at a time) *

Varies from meal to meal.
Large as compared to most other people.
Small as compared to most other people.

Fluctuations of body weight *

Easy to loose, difficult to gain; I tend to be underweight.
Can maintain normal weight even with fairly large food intake.
I gain weight easily, even with moderate food intake. Difficult to lose weight.

Energy level *

Variable or low compared to others.
Abundant compared to others.
Good, but may tend toward laziness.

Regularity of bowel movements *

Irregular, tending toward constipation.
Frequent; often more than 1-2 times a day.
Regular, once or twice daily.

Quality of stool *

Hard, dry.
Loose.
Well-formed.

Select each of the symptoms listed that applies to you: *

a. Gas or bloating
b. Frequent belching
c. Constipation
d. Intestinal cramping or discomfort
e. Acid stomach
f. Reflux (heartburn)
g. Diarrhea tendency
h. Sluggish digestion (regularly, not variable)
i. Heaviness or sleepy after eating (often)
j. Stool sticky or with mucus

Brief Prakriti Assessment By Dosha Predominance

Face/Complexion (5) *

Oval or thin, pale or grayish complexion
Reddish or ruddy complexion, early wrinkling
Fair, clear, “glowing” complexion

Psychomotor movements/gait/speech (5) *

Quick, always moving
Purposeful, sharp, precise, stable
Methodical, relaxed, slow, stable

Body weight (7.5) *

Light
Medium
Heavy

Body frame (7.5) *

Small-boned, bony, angular; less muscular
Medium frame and musculature
Large frame, sturdy, plump, good/large musculature

Joints (5) *

Prominent bony protuberances
Medium
Rounded, well- covered

Eyes, size and shape (2.5) *

Small, deep-set or protuberant
Medium size, sharp or penetrating appearance
Large

Tendons and Veins (5)

Prominent, very visible
Medium prominence and visibility
Well-covered, hidden

Abdominal wall thickness (5) *

Thin
Medium
Thick (increased adipose tissue)

Skin quality (5) *

Tends toward dryness
Fair, burns easily
Tends toward oiliness

Temperature intolerance (2.5) *

Cold temperature
Hot temperature
Cool and damp, or comfortable at most temperatures

Typical emotional reaction to challenges (2.5) *

Worry, anxiety
Anger, irritability
Generally remains stable, calm

Physical strength and stamina (2.5) *

Variable or low compared to others.
Medium to strong compared to others.
High compared to others.

General Health Survey

Please mark to what degree the following statements apply to you (1=0% and 5=100%):

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