Three Seasons Ayurveda Confidential Health History Paperwork
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. Attach Western medical reports below.
What is your height & weight*
My emergency contact person is: (name, relationship, phone).*
My partner status is; single, married, divorced?*
If you have children what are their names and ages?*
What are your three main objectes to achieve with Ayurveda?*
What are your health concerns?*
Do you have any allergies (environmental, food, seasonal, etc.)?*
Primary physician name and location:
*
Please share any blood test results that are concerning: (cholesterol, A1C, glucose, etc.). You can also upload current documents below.*
Do you see other doctors or health practitioners (who, modality, and how often)?
Family health history
(List family members, illnesses, diseases, and conditions you fear are hereditary.
Do you drink alcohol: how often? What kinds do you prefer?*
Have you smoked tobacco? If so, how much per day, and if you quit, when?*
Do you or have you used recreational drugs? (List types, current usage and if you quit, when.)*
Sleep- how many hours per day, list bedtime and awake time? *
My current sleep quality is:*
What are your creative interests and hobbies? (music, art, gardening, etc.)*
What is your exercise regime: (types, how ofter, duration)*
Do you have a primary intimate relationship and if so for how long?*
Explain your religious beliefs and associations:*
What are your spiritual practices? (meditation, journaling, yoga, prayer, etc.)*
Do you have any addictions? (food, drugs, gambling, sex, etc.)*
MEN- Any issues to share (prostate, urinary, etc.)
WOMEN- Explain your menstrual patterns (regularity, flow, comfort) through your life and present. (menopausal, etc.)
Describe your regular daily schedule with work and routines, including times and activities:*
Do you have a daily commute, how far?*
Do you travel regularly, and if so, how often?*
Describe your breakfast & time:*
Describe your lunch & time:*
Describe your dinner & time:*
Do you snack during the day? How often, and what do you like?*
How much water do you drink per day*
Do you drink caffeine, what type and how much.*
What OTHER beverage/s do you intake daily: dairy milk, nut or grain milk, tea, juice? Be specific with amounts.*
Currently my digestion Is:*
How many bowl movements daily?*
Currently, emotionally I feel*
My appetite and eating patterns are:*
When I have to make a decision, I usually experience:*
When I miss a meal, I feel?*
List all medications and dosages- DETAILED*
List all supplements, vitamins and herbal formulas currently taking:*
Please tell me anything else you would like to share with me .*
Informed Consent & Financial Agreement
The National Institute of Health Office considers Ayurveda a form of complementary and alternative medicine in the United States. In California, Ayurveda is a non-licensed profession, and its practice was legalized by 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.
All fees are due at the time of service.
There is a $95 fee for cancellations without a 24-hour notice.
Fees are refundable 24 hours before your appointment.
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 that I have been advised of the financial policies, potential risks, and the benefits of holistic treatments, and I release Jeff Perlman and Three Seasons Ayurveda from any liability and responsibility.
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