Ayurveda TRAININGIntake FormIntake FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeWhat time zone are you in?How old are you?Emergency contact Name & phone numberHow did you hear about La Vida Veda Ayurveda?Word of mouthFacebookTwitterGoogleYelpReason for VisitayurvedamassageHEALTH HISTORY: Please check any symptoms that you have experienced past or presentAllergiesAuto-immune diseasesAsthmaAlcoholism/AddictionsArthritisBlood clotsCancerChronic fatigueChronic painDiabetesDepressionDizzinessEpilepsyEndometriosisFibromyalgiaGoutHeart diseaseHepatitisHigh blood pressureLow blood pressureHearing problemsHerniasHeadaches or migrainesNumbness/TinglingPCOSPneumoniaProstate problemsSeizuresSexually Transmitted DiseasesStrokeThyroid diseaseUlcersVaricosities (including hemorrhoids)Vision problemsWhooping coughYeast infectionsPlease note any family history of the above conditions:GENERAL SYMPTOMS Please check any symptoms that you have experienced past or present:Poor appetiteHeavy appetiteWeight lossWeight gainFatigueHeartburnFrequent urinationStrange tastesEdemaEczemaTMJDCold hands and feetPoor circulationDiarrheaConstipationShortness of breathIndigestionItchy skinSleep difficultiesHeart palpitationsPsoriasisSinus problemsNight sweatsTinnitus (ringing in ears)Bleed or bruise easilyExcessive sweatingDifficulty concentratingGas/bloatingHair lossFrequent infectionsAnxietyWartsMuscle/Joint problemsOther symptoms: (please specify):Do you have allergies or sensitive skin towards any essential oils, massage oils, massage lotions or ointments?YesNoFOR WOMEN : Onset of menstruationWOMEN: Please check any symptoms that you are experiencing:Irregular menstruationSpottingBack painMenopausalMiscarriagesPainful periodsAbsent periodsHighly emotionalHot flashesPregnantBreast tendernessHeavy periodsPre-menopausalClotting Breast feedingIf yes, for how long?Do you use other forms of birth control? If yes what forms and for how long?# of live births and datesHave you experienced birth traumas?If yes, please elaborate:How much water do you drink a day?Do you smoke?YesNoIf yes, for how long and how frequently?Do you exercise?YesNoIf yes, what type of exercise and how frequently?Rate your stress level on a scale of 1 – 10, 10 being very stressedDo you drink caffeine?YesNoIf yes, how much?Do you use drugs?YesNoIf yes, what drugs and how often?Rate your diet on a scale of 1 – 10, 10 being idealAre you happy? Why or why not?Are you currently taking any pharmaceuticals, herbal medicines, homeopathic remedies, flower essences or other supplements? If yes, please list belowIs there anything else that you think I should know about you and your health?How can I best help you?Cancellation Policy: In signing this form, I acknowledge a mutual understanding of the value of our time. I understand that 48 hours’ notice is required to reschedule or cancel any appointments with La Vida Veda Ayurveda & Yoga. The full fee will be charged for missed appointments. 50% will be charged for appointments cancelled less than 48 hours in advance. I have read and agree to the 48 hour policy. PLEASE PUT YOUR FIRST AND LAST NAME BELOW. *Submit
