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

Month

Day

Year

First name

Last name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Cell phone number

My birthday

Month

Day

Year

My age is:

What is your current weight, your goal, and your height?

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?

My occupation is:

I was referred to you by:

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:

Submit Medical Records

If you have current blood tests or other applicable documents, please upload them.

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 are your preferences?

Do you or have you smoked tobacco, and 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, what is your bedtime and awake time?

My current sleep quality is:

What are your creative interests? (music, art, gardening, photography, etc.)

What is your exercise regime? (types, how often and duration)

Eo you have a primary intimate relationship and if so for how long?

Explain your religious 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?

What beverage/s do you intake daily: water, coffee, milk, nut and grain milk, tea, juice? Be specific with amounts.

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?

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 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.

All fees are due at the time of service.
There is a $95 fee for cancellations without 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 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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