Ayurvedic Health Questionnaire

Please take the time to fill out this questionnaire carefully so that we may provide you Wirth a complete evaluation. All of your answers will be held absolutely confidential. If you have any questions, please contact us.

Personal medical history:
Family medical history:
Habits - Alcohol:
Habits - Coffee:
Habits - Tea:
Habits - Tobacco:
Habits - Exercise:
Habits - Sleep:
Habits - Appetite:
Habits - Medication:
Habits - Vitamins:
Habits - Food Intake:
Habits - Salt Intake:
Habits - Stress Level:
Symptoms - General (last 3 months):
Symptoms - Skin & Hair (last 3 months)
Symptoms - Head (last 3 months):
Symptoms - Eyes/Ears/Nose/Throat (last 3 months):
Symptoms - Cardiovascular (last 3 months):
Symptoms - Respiratory (last 3 months):
Symptoms - Musculoskeletal (last 3 months):
Symptos - Gastrointestinal (last 3 months):
Symptoms - Genito/Urinary (last 3 months):
Symptoms - Neuropsychological (last 3 months):
Symptoms - Pregnancy & Gynecology (last 3 monhs):

We keep medical records of the health care services we provide for you. You may ask to see a copy of your records. You may ask to correct your records. Your records will be kept confidential unless you give us written permission to release them or we are required to do so by law.

Your Signature

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