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Thank you for choosing Three Seasons Ayurveda for your holistic healthcare needs. In preparation for your first appointment, please complete the form below, and return to Three Seasons Ayurveda no later than 48 hours before your first appointment to help me prepare for your visit.​​​​​​​

Three Seasons Ayurveda

Confidential Health History Paperwork

Instructions: Please complete this Health History questionnaire as thoroughly as possible; know that all information is confidential and will not be shared with anyone without your permission. You can attach Western medical results below.

Todays Date
My birthday
My current sleep quality is:
Currently my digestion Is:
How many bowl movements daily?
What is the quality of your elimination?
Currently emotionally I fee:
Interaction with people
My appetite and eating patterns are:
Working on projects:
When I have to make a decision, I usually experience:
My Weight HIstory Is:
When I miss a meal, I feel?
My body temperature is:
When stressed, I feel?
When balanced I feel?
My skin is?

Informed Consent & Financial Agreement

The National Institute of Health Office of Complementary and Alternative Medicine considers Ayurveda a form of complementary and alternative medicine in the United States. In the State of California, Ayurveda is a non-

licensed profession and its practice was legalized under the passage of Senate Bill 577.


Jeff Perlman, the principal of Three Seasons Ayurveda, is not a medical doctor but is certified by the National Ayurvedic Medical Association, the American Herbalist Guild, the California Massage Therapy Council, the International Association of Yoga Therapists, and the American Culinary Association.


I acknowledge that Jeff Perlman and Three Seasons Ayurveda are not medical physicians, pharmacists, or nurse practitioners and cannot legally diagnose, prescribe, treat, or claim to cure diseases.


  1. All fees are due at the time of service.

  2. There is a $95 fee for cancellations without 24-hour notice.

  3. Fees are refundable 24 hours before your appointment.

  4. Three Seasons Ayurveda accepts all credit cards, Venmo, Zelle, checks, and cash.


Three Seasons Ayurveda does not bill insurance companies.

By signing this document, I acknowledge I have been advised of the financial policies and all risks, contridiction, and the benefits of holistic treatments and release Jeff Perlman and Three Seasons Ayurveda from any responsibility.

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