Please Help Us Prepare for Your Arrival

In order to facilitate the ayurvedic counseling we provide, we ask that you fill out this form prior to the retreat.  This way, our ayurvedic counselor, Mike, can be prepared for your arrival and we can make adjustments to your diet, if necessary, for the retreat. More importantly, a plan can be prepared for your return home.  We have found that the guidance of ayurvedic principles has a tremendous benefit in the integration process and the maintenance of health and healthy lifestyles.  This information is all confidential.  Thank you.

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  2. (valid email required)
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  6. MEDICAL HISTORY


    Include major conditions, dates of treatment, and procedures performed
  7. CURRENT MEDICATIONS, HERBS, & SUPPLEMENTS


    Please list any medications, herbs, and supplements that you are currently taking as well as any significant remedies that you have recently stopped taking.
  8. FAMILY HISTORY


    Please provide information for your relatives. For each condition, list any applicable details and the relative(s) afflicted.
  9. FOODS & BEVERAGES


    Please list what types of foods do you eat on a regular basis.
  10. HABITS & ROUTINES

  11. DAILY SCHEDULE


    Describe your activities from the time you wake up until you go to sleep (eating, exercise, work, etc.)
  12. CURRENT HEALTH EVALUATION


    Please fill out the following information for the symptoms you are currently experiencing with the following details:
    FREQUENCY: Number of times per day, week, or month (1W, D, 3M, ongoing, etc)
    INTENSITY: 1-10 range 1 - mild, 4 - strong enough to seek support, 10 - shutting you down in some way
    ONSET: When the symptom started (2M ago, 5Y ago, age 20, etc)
    DURATION: how long the symptoms last (constant, 20min, 2hrs, etc)
    Example: 4W (4x/week) - 2 (mild) - 6M (6 months ago) - 2hrs
    (If you do not experience the symptom simply leave it blank)
  13. MIND & EMOTIONS: Frequency - Intensity - Onset - Duration
  14. DIGESTION & ELIMINATION: Frequency - Intensity - Onset - Duration
  15. OTHER SYMPTOMS - HEAD: Frequency - Intensity - Onset - Duration
  16. OTHER SYMPTOMS - EARS & NOSE: Frequency - Intensity - Onset - Duration
  17. OTHER SYMPTOMS - EYES: Frequency - Intensity - Onset - Duration
  18. OTHER SYMPTOMS - MOUTH: Frequency - Intensity - Onset - Duration
  19. OTHER SYMPTOMS - NECK: Frequency - Intensity - Onset - Duration
  20. OTHER SYMPTOMS - CHEST: Frequency - Intensity - Onset - Duration
  21. OTHER SYMPTOMS - SKIN: Frequency - Intensity - Onset - Duration
  22. OTHER SYMPTOMS - URINARY: Frequency - Intensity - Onset - Duration
  23. OTHER SYMPTOMS - MUSCLES & JOINTS: Frequency - Intensity - Onset - Duration
  24. OTHER SYMPTOMS - NERVES: Frequency - Intensity - Onset - Duration
  25. OTHER SYMPTOMS - CIRCULATION: Frequency - Intensity - Onset - Duration
  26. OTHER SYMPTOMS - FEMALE SYSTEM: Frequency - Intensity - Onset - Duration
  27. OTHER SYMPTOMS - MALE SYSTEM: Frequency - Intensity - Onset - Duration
  28. OTHER SYMPTOMS: Frequency - Intensity - Onset - Duration
  29. FUNCTIONAL HISTORY

  30. For Each Catagory, please identify your primary tendency over time by choosing what best describes you. If unsure, leave blank
  31. WOMEN ONLY
  32. For menstrual cycle, answer most common long-term pattern
  33. EVALUATION OF MANAS

  34. For each category, please identify your primary tendency over time. If unsure, leave blank