Name
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First Name
Last Name
Preferred Pronouns
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Email
*
Address
City, State, Zip
*
Phone
Country
(###)
###
####
Occupation
Age
Birthdate
MM
DD
YYYY
Optional: Birth Time + Location
Are you under the care of a licensed health care professional or any other healthcare provider?
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If so, for what reasons:
Serious illnesses:
Major Hospitalizations or Operations:
List any pertinent past or present conditions:
Have you had any cosmetic surgery or procedures performed?
Are you pregnant?
Indicate what members of your immediate family have had these conditions. {Go back one generation}.
If you checked any boxes above, please describe
Do you drink alcoholic beverages
If yes, how often?
How many 8oz servings?
I usually choose
Do you smoke any substances?
If yes, how often?
If you have quit smoking, what year did you quit?
Any current or past use of addictive habitual substances?
If yes, please describe how this affected you, any insights, or your experience.
How often do you exercise?
This includes any form of cardio, sports, vigorous asana practice, brisk walking, running, etc.
Do you participate in any team sports or recreational activities? If so, please describe.
If so, how often?
Do you travel for leisure? If so, please describe.
How often do you travel for leisure?
Do you travel for work? Include your commute.
If you travel for work, specify how often.
If so, how often do you partake in your spiritual practices?
Do you practice meditation / prayer / pranayama?
If so, how often do you practice?
Are there any other prominent activities that you'd like to share as part of your regular practices?
How often do you engage in sexual activity?
This includes sex with partner{s} and/or masturbation.
Are you satisfied with your current sex life?
Breakfast
Lunch
Dinner
Snacks
What percentage of your food is organic?
Check which beverage{s} you have on a daiy basis
When it comes to eating patterns, describe any current or past eating patterns or other food related issues.
Describe your day below.
Do you have any allergic reactions to any substances?
Include food or medicines. If yes, please specify.
Appetite
Appetite
Digestion
Elimination
Elimination
Weight
Body Temperature
Sleep
Dreams
My dreams are usually
Stress
Decision Making
Projects
Personality
Personality: How would a friend descibe you?
Digestion
Check any of the following you experience often.
Elimination
Check any of the following you experience.
Emotions
Check any that pertain to you
Energy Levels
What is your energy level on scale of 1-10, 1 being depleted and 10 being fully energized. Describe any details you'd like to share here.
Describe your menstrual cycle. If you are in menopause, please make note below, describe your transition and answer the remaining questions as a reflection of when you did have menstruation.
My menstrual cycle is
My menstrual flow is
The pain I experience during menstruation is
Heightened emotions I tend to experience during my cycle include
Physical Health and Wellbeing
Emotional Health and Wellbeing
Career
Fun and Leisure
Significant Other(s)
Family
Friends
Financial Health
Education and Personal Growth
Spirituality / Religion
Lifestyle
Balance in Life
Describe your top 3 areas you'd like to focus on most.
Choose from the above list.
If you could create results you desired in these top 3 areas, what specifically would you like to achieve?
As a counselor, how can I best support you to achieve your goals?
Agreement
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By checking this box I confirm that I have read and agree to the Ayurvedic Counseling Terms of Service and Policies. I release liability and take full responsibility for my participation in my health journey.
Full terms, conditions and cancellation policy here: www.gabycolletta.com/ayurvedic-counseling-terms-of-service
