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.

1. Name(required)
2. Email(valid email required)
3. Date of Birth(required)
4. Month and Year of Program You're Attending(required)
5. Age(required)
6. Marital/ Partner Status
7. Number of Children
8. Ages of Children
9. Occupation
10. Does your job give you satisfaction and/or stress? Please describe
11. What are your main health concerns at this time?

12. MEDICAL HISTORY

    
    Include major conditions, dates of treatment, and procedures performed
13. Past serious illnesses
14. Past Hospitalizations
15. Past Operations
16. Other pertinent past conditions
17. Have you been under the care of a licensed health care professional in the past year?
18. If so, for what reasons?
19. Is there a possibility that you are pregnant?
20. List Current Diagnosed Conditions Please number them (1. 2, 3, etc.)
21. Treatment for above conditions. Use numbers from above for each condition

22. 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.
23. List them as follows: Name - Beginning/End dates - Dosage - Purpose: Please number them

24. FAMILY HISTORY

    
    Please provide information for your relatives. For each condition, list any applicable details and the relative(s) afflicted.
25. Cancer: detail - relative
26. Stroke: detail - relative
27. Diabetes: detail - relative
28. Heart Disease: detail - relative
29. Mental Disorder: detail - relative
30. Other: detail - relative

31. FOODS & BEVERAGES

    
    Please list what types of foods do you eat on a regular basis.
32. Breakfast:
33. Lunch:
34. Dinner:
35. Snacks:
36. Describe any routines you have around eating
37. Describe any current or past problems with chronic eating disorders or other food related issues
38. List any allergic reactions to any substances. please number each substance
39. How many cups of caffeinated beverages do you drink per day?
40. What types? (coffee, tea, soda)
41. How much water do you drink per day? number of glasses
42. Other non-caffeinated beverages you drink per day. number of cups/glasses
43. What types? (coffee, tea, soda, milk, juice)
44. How many glasses alcohol do you drink per week?
45. What types? (beer, wine, liquors, hard alcohol)

46. HABITS & ROUTINES

47. Describe any regular spiritual practices/ meditation
48. Describe your exercise routine
49. Describe any creative activities
50. If you smoke, how many cigarettes do you smoke per day?
51. If you smoked in the past, how much did you smoke and when did you quit? Amount - MM/DD/YYYY
52. Do you currently or have you had problems with substance abuse? Yes/No - Past/Current
53. Please list the substances and when you were using them
54. How many hours of sleep do you get per night?
55. Do you feel well-rested with enough energy to get through your day?

56. DAILY SCHEDULE

    
    Describe your activities from the time you wake up until you go to sleep (eating, exercise, work, etc.)
57. Awaken: What time - Activities
58. Breakfast: What time - Activities
59. Morning: Activities
60. Lunch: What time - Activities
61. Afternoon: Activities
62. Dinner: What time - Activities
63. Evening: Activities
64. Bedtime: What time - Activities
65. Additional Comments about Daily Activities
66. What would you like to work on changing in your diet, lifestyle, etc?

67. 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)
68. MIND & EMOTIONS: Frequency - Intensity - Onset - Duration
69. Worry
70. Anxiety/Fear
71. Overwhelm
72. Spaciness
73. Self Destructiveness
74. Difficulty remembering
75. Anger/Rage
76. Resentment
77. Jeaslousy/Envy
78. Being Critical
79. Lethargy
80. Sadness
81. Depression
82. Insomnia/Disrupted Sleep
83. DIGESTION & ELIMINATION: Frequency - Intensity - Onset - Duration
84. Colicky Digestive Pain
85. Burning Indigestion
86. Belching
87. Regurgitation
88. Vomiting
89. Excessive Gas
90. Heavy/Bloat after Eating
91. Hemorrhoids
92. Constipation (<1BM/day)
93. Diarrhea/ loose stools
94. Constipation/ Diarrhea
95. Bloody Stool
96. Anal Itching
97. OTHER SYMPTOMS - HEAD: Frequency - Intensity - Onset - Duration
98. Headaches
99. Dizziness
100. Fainting Spells
101. Loss of Balance
102. Thinning/ Loss of Hair
103. OTHER SYMPTOMS - EARS & NOSE: Frequency - Intensity - Onset - Duration
104. Hearing Loss
105. Ringing in the Ears
106. Earaches
107. Loss of Smell
108. Nose Bleeding
109. Nose Discharge
110. Post-Nasal Drip
111. Sinus Congestion
112. OTHER SYMPTOMS - EYES: Frequency - Intensity - Onset - Duration
113. Painful/ Sore Eyes
114. Red Eyes
115. Burning Eyes
116. Mucous in the Eyes
117. Dry Eyes
118. Itchy Eyes
119. Blurred/ Loss of Vision
120. OTHER SYMPTOMS - MOUTH: Frequency - Intensity - Onset - Duration
121. Excessive Thirst
122. Bad Breath
123. Lip Ulcers/ Lesions
124. Dry/ Cracking Lips
125. Bleeding Gums
126. Receding Gums
127. Tooth Pain
128. TMJ
129. OTHER SYMPTOMS - NECK: Frequency - Intensity - Onset - Duration
130. Pain/ Stiffness
131. Swollen Glands
132. OTHER SYMPTOMS - CHEST: Frequency - Intensity - Onset - Duration
133. Chest Pain
134. Tightness/ Pressure
135. Heart Palpitations
136. Shortness of Breath
137. Painful/ Difficult Breathing
138. Persistent Cough
139. Frequent Chest Colds
140. OTHER SYMPTOMS - SKIN: Frequency - Intensity - Onset - Duration
141. Dry/ Flaky Skin
142. Rashes
143. Acne
144. Changing/ Bleeding Moles
145. Fungus/ Eczema/ Psoriasis
146. OTHER SYMPTOMS - URINARY: Frequency - Intensity - Onset - Duration
147. Painful Urination
148. Urine Retention/ Dribbling
149. Frequent Urination
150. Blood in Urine
151. Kidney/ Bladder Infections
152. OTHER SYMPTOMS - MUSCLES & JOINTS: Frequency - Intensity - Onset - Duration
153. Swelling in Joints
154. Pain/ Ache/ Stiff in Joints
155. Muscle/ Bone Pain
156. Muscle Weakness/ Atrophy
157. OTHER SYMPTOMS - NERVES: Frequency - Intensity - Onset - Duration
158. Loss of Sensation
159. Tingling Sensation
160. Tremors in Limbs
161. Uncoordinated Muscles
162. Fatigue/ Stress
163. OTHER SYMPTOMS - CIRCULATION: Frequency - Intensity - Onset - Duration
164. Varicose Veins
165. Cold Hands/ Feet
166. Swollen Ankles
167. Calf Pain
168. OTHER SYMPTOMS - FEMALE SYSTEM: Frequency - Intensity - Onset - Duration
169. Are you Menopausal? Yes/No - Date of last period
170. Irregular Cycle
171. Heavy/ Prolonged Bleeding
172. Missed Menses
173. Painful Menses/ Cramps
174. Spotting/ Discharge
175. PMS Symptoms (bloating, headaches, weight gain, irritable, breast tenderness
176. Miscarriage/ Infertility
177. Genital Stores/ Herpes
178. Ovarian Cyst/ Fibroids
179. Hot Flashes
180. Vaginal Itching
181. OTHER SYMPTOMS - MALE SYSTEM: Frequency - Intensity - Onset - Duration
182. Swollen/ Painful Prostate
183. Low Sperm Count
184. Low Sperm Motility
185. Genital Sores/ Lesions
186. Genital Discharge
187. Erection Difficulty
188. Herpes
189. OTHER SYMPTOMS: Frequency - Intensity - Onset - Duration
190. Any Symptom not covered above (Please number and list)

191. FUNCTIONAL HISTORY

192. For Each Catagory, please identify your primary tendency over time by choosing what best describes you. If unsure, leave blank
193. AppetitePlease selectMy hunger level is variable and I often forget to eatI have a strong appetite and don't like to miss meals. I often need snacks in addition to my meals and really enjoy eatingI don't have a strong appetite but I like to eat and often eat because the clock says it's time, food is there, or I want emotional comfort
194. AppetitePlease selectIf I miss a meal I often get light-headed, anxious or emotionalIf I miss a meal I often get irritable or crankyI can go without eating without much discomfort, but I usually don't miss meals
195. AppetitePlease selectI prefer to eat frequent, small meals and no set schedule. I often forget to eatI prefer to eat 3 meals a day at about the same time and rarely skip mealsI prefer to eat 2-3 times daily but can go without eating, though I usually don't
196. DigestionPlease selectAfter eating I often experience gas, bloating, and colicky painAfter eating I often experience heartburn and acidityAfter eating I often feel heavy, sluggish, or sleepy
197. EliminationPlease selectI tend to have irregular bowel movements, going one time a day or lessI usually have 1-3 bowel movements a day with regularityI tend to have one bowel movement a day with no straining or difficulty
198. EliminationPlease selectMy bowel movments are often dry and hard. At times I may strain or pushMy bowel movements are soft with some form but at times may be loose and burnMy bowel movements are usually well-formed, bulky and large, slow and easy
199. WeightPlease selectI usually don't gain weight very easily or my weight fluctuates but is easy to loseMy weight is mostly steady and if I gain weight it is easy to lose. I notice a slow gain as I get older that is harder to loseI gain weight easily and lose it slowly with difficulty
200. Body TemperaturePlease selectI am often cold. My hands and feet often feel coldI am warm most of the time no matter what the season or climateI adapt easily to most situations but tend to feel cooler
201. Seasonal DiscomfortPlease selectI am most bothered by the cold of the winterI have a hard time with the heat of summerI am comfortable in most seasons though can be bothered by humidity and dislike the rain and gray in spring
202. SkinPlease selectMy skin tends to be dry. When very dry it feels rough and may crackMy skin tends to be sensitive to sun and chemicals. It is often flushed and rosyMy skin is thick, smooth, and often feels damp or oily
203. SkinPlease selectWhen I have rashes they tend to be dry and itchy. Blemishes are usually blackheadsWhen I have rashes they tend to be red and burning. Blemishes are usually acneWhen I have rashes they tend to be wet and oozing. Blemishes are usually white pimples
204. SweatPlease selectI hardly sweat and only due to lots of heat or physical exertionI sweat profusely without much heat or exercise. My sweat has a strong odorI sweat easily and take longer to stop after exercise. My sweat has a mild odor
205. SleepPlease selectI sleep lightly and awaken easily if rested. It can be difficult to fall asleep. My sleep is often disruptedI tend to sleep soundly unless hot. I may awaken but fall back to sleep easily. I awaken with ease as a morning personMy sleep tends to be deep and long. I fall asleep easily and quickly. It is difficult for me to awaken in the morning
206. WOMEN ONLY
207. For menstrual cycle, answer most common long-term pattern
208. PMS symptoms (select more than one symptom using shift-select) crampsheadachesbloatingweight gainirritablebreast tenderness
209. I experience PMS: Please selectoftenoccasionallyrarely
210. I started my menses at age:Please select9-1212-1414-16
211. My menstrual cycle is:Please selectregularirregular
212. My menstrual cycle come every __ to __ days and lasts __ days: Fill in as: # to # days - lasts # days
213. My menstrual flow is:Please selectoften light but it may varyheavy/profuse and is usually consistentmoderately heavy and very consistent
214. Menstrual PainPlease selectI often have severe cramping pain during mensesAt times I have mild/moderate sharp pains during mensesI rarely have pain during menses and if I do it is dull

215. EVALUATION OF MANAS

216. For each category, please identify your primary tendency over time. If unsure, leave blank
217. StressPlease selectUnder stress I often become anxious and overwhelmed. I have trouble functioning and feel scatteredUnder stress I become irritable but am able to rise to the challenge and work through itUnder stress I often withdraw to observe or become reclusive. I can also be less bothered by stress
218. Decision MakingPlease selectI am changeable and often have difficulty making decisionsI make decisions easily with confidenceI am careful and slower to make decisions but easy-going
219. Decision MakingPlease selectI can be indecisive and easily influenced by othersI change decisions based on new information that makes senseI do not like changing my decisions and can be stubborn
220. ProjectsPlease selectI like to start many new projects but often don't finish most of themI start projects easily but like a plan because completion is important to meI like working on projects but prefer that others start them. On my own, I may get caught in the planning and not start
221. ProjectsPlease selectMy projects don't get finished because I get distracted or I can procrastinate due to feel overwhelmedI can manage several projects at once and like to finish on time or easilyI work slowly and steadily, often taking a long time to finish
222. Mental NaturePlease selectI am quick to learn but do not retain information well long termI have a sharp, clear memoryI am slower to learn but once I have it, I don't forget
223. Mental NaturePlease selectI thrive on new experiences and am adaptable. I am challenged to hold routinesI have a strong intellect and enjoy solving problems and digesting information. Discipline and organization are important to meI prefer regularity and am less comfortable with change and spontaneity