Ayurvedic Treatment Intake Form

Please complete the following form in order to provide us with the background information we require to ensure you receive
comprehensive care. It should take 15-20 minutes.
Contact Information:

Name Occupation
Gender (circle) Male Female Employer
Date of Birth Work Phone # ( )
E-mail Address Emergency Contact
Home Phone # ( ) Emergency Contact # ( )
Cell ( ) Contact Relationship

Home Address OHIP Number

YES I NO Can we send you our seasonal newsletter and monthly calendar of events via email.
Your email address will not be shared.

How did you hear about the Integrative Health Institute? (If another person, please provide name)
_____________________________________________________________________________
Care Co-ordination:
Medical Doctor Specialist
Medical Doctor #( ) Specialist # ( )
Medical Doctor Specialist
Address Address
Email Email
Dentist Specialist
Dentist # ( ) Specialist # ( )
Dentist Specialist
Address Address
Email Email

Please List any other Medical Providers:

Type of Medical Provider Name Phone # Address

Integrative Health Institute

46 Sherbourne Street, 2nd Floor I Toronto ON I M5A2P7 I 416.260.6038
 Initial Questionnaire and History
Take this as an opportunity to bring awareness to areas of your life that may need more loving attention. Take your
time and answer as honestly as possible

1. What are you currently doing in your life that brings you peace, health, balance and/or nurtures your soul?

2. What would you like to get out of the Ayurvedic Consultation?

a)

b)

c)

3. Which areas in your life are you most interested in bringing balance to?

4. What results do you want to produce in your physical body?

5. What results do you want to produce in regards to your mental and emotional well-being? Do you find yourself
anxious, stressed, depressed, or easily brought to annoyance or anger?

6. What would you have to give up to have the results you want?

Integrative Health Institute

46 Sherbourne Street, 2nd Floor I Toronto ON I M5A2P7 I 416.260.6038
 CHIEF HEALTH CONCERNS
What are your main health concerns at this time? Order by importance to client.
PRIMARY CONCERNS CLINICIAN NOTES

PAST MEDICAL HISTORY

Include major conditions, dates of treatment and procedures performed.

1. Serious illnesses: ________________________________________________________________________________

____________________________________________________________________________________________________

2. Hospitalizations: _________________________________________________________________________________

3. Operations: _____________________________________________________________________________________

4. List other pertinent past conditions: ________________________________________________________________

__________________________________________________________________________________________________

5. Have you been under the care of a licensed health care professional in the past year? !Yes !No

If so, for what reasons: _____________________________________________________________________________

6. Is there any possibility that you are pregnant? ! Y ! N

FAMILY HISTORY PLEASE CHECK THE APPROPRIATE BOXES AND INDICATE FAMILY MEMBER.
q Cancer q Diabetes
q High Blood Pressure q Heart Disease
q Stroke q Mental Disorder
q Other (explain) q Other (explain)

Integrative Health Institute

46 Sherbourne Street, 2nd Floor I Toronto ON I M5A2P7 I 416.260.6038
 CURRENT MEDICATIONS, HERBS OR SUPPLEMENTS
What medications, herbs, supplements are you currently taking?
Please include significant remedies that you have recently stopped taking.

Name of substance:

q Prescription q over-the-counter q herbal q vitamin q other

Who recommended/prescribed it?

Purpose of substance:

How long have you been taking it:

In what form do you take it (include dosage):

Name of substance:

q Prescription q over-the-counter q herbal q vitamin q other

Who recommended/prescribed it?

Purpose of substance:

How long have you been taking it:

In what form do you take it (include dosage):

How often do you take it?

Name of substance:

q Prescription q over-the-counter q herbal q vitamin q other

Who recommended/prescribed it?

Purpose of substance:

How long have you been taking it:

In what form do you take it (include dosage):

How often do you take it?

Integrative Health Institute

46 Sherbourne Street, 2nd Floor I Toronto ON I M5A2P7 I 416.260.6038
 DAILY ROUTINES

DAILY SCHEDULE (include approximate times)

1. Describe your activities from the time you wake up until you go to sleep. (Eating, sleeping, exercise, work, activities).
Time Activities
Morning VARIATIONS
Awaken
Breakfast
Activities

Mid-day
Lunch
Activities

Evening
Supper
Activities

Night
Activities
Bed-time

2. List regular practices that are not included above, e.g., exercise, meditation, spiritual practices, etc.

3. Are you sexually active? Y ! N ! Frequency?

4. What types of food(s) are eaten on a regular basis?

BREAKFAST:

LUNCH:

DINNER:

SNACKS:

Integrative Health Institute

46 Sherbourne Street, 2nd Floor I Toronto ON I M5A2P7 I 416.260.6038
 5. Are there any routines around eating:

6. Any current or past problems with chronic eating disorders or other food related issues? ! Y ! N

ALLERGIES OR SENSITIVITIES
7. Do you have allergic reactions to any substances? If yes, please list.

GENERAL HEALTH HABITS

8. How many cups of caffeinated beverages do you drink per day?
# ______________________________ Type(s) of beverage: coffee/tea/soda

9. How many cups of non-caffeinated beverages do you drink per day? # _______________________
Type(s) of beverage: herbal tea/milk/juice/other _________________________________________

10. How much water do you drink per day?__________________________________________________

11. Do you exercise regularly? ! Y ! N Length of time: ______________________________________

Times per week: _________________________
Type(s) of exercise: _______________________

12. If you smoke, how many cigarettes do you smoke per day?____Have you ever smoked? ! Y N !
Amount/day: ____________ When quit? ______________________________________________

13. If you drink alcohol, how many glasses of alcohol per week? (Include beer, wine, liqueurs and hard liquor)
# _________________per week Type(s) of beverage:_________________________________

14. Any current or past problems with addiction or substance abuse? ! Y ! N

Substance: _______________________________ Amount: _________ When quit? __________

15. Please describe current digestive patterns (i.e. regular/irregular B.M., diarrhea, constipation, indigestion, strong/
dull appetite):
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________

16. Body temperature: Do you generally run warm or cold? Please explain: _______________________
____________________________________________________________________________________

Integrative Health Institute

46 Sherbourne Street, 2nd Floor I Toronto ON I M5A2P7 I 416.260.6038
 REVIEW OF SYMPTOMS
Check all symptoms that are of concern to you at this time that you want to discuss with the practitioner. Please
indicate any area in which you have experienced a severe episode and indicate if episode was in previous 6 months or
prior to 6 months time.
Concern Office HEAD Concern MOUTH
Office
Headaches Excessive thirst
Dizziness Loss of taste
Fainting spells Strange taste
Loss of balance Bad breath
Difficulty remembering Lip ulcers or lesions
Difficulty thinking clearly Dry/cracking lips
Thinning or loss of hair Tongue pain
Bleeding gums
Receding gums
Concern Office EARS Tooth pain
Hearing loss TMJ
Ringing
EarachesPain
Discharges Concern NECK
Office
Bleeding Pain
Swollen glands
Lumps
Concern Office EYES Stiffness
Painsoreness in eyes
Redness
Burning Concern CHEST
Office
Mucous Pain in chest
Dryness Tightness/pressure in chest
Itching Heart palpitations
Tic/twitch Shortness of breath
Blurred/loss of vision Painfuldifficult breathing
Persistent cough

Frequent chest colds

Integrative Health Institute

46 Sherbourne Street, 2nd Floor I Toronto ON I M5A2P7 I 416.260.6038
 NOSE SKIN
Concern Office Concern Office
Loss of smell Dryflakey
Bleeding Rashes
Pain Blisters
Discharge Acne
Post-nasal drip Changing or bleeding moles
Sinus Congestion Response to insect bites

Integrative Health Institute

46 Sherbourne Street, 2nd Floor I Toronto ON I M5A2P7 I 416.260.6038