Health Intake Form AUTHORIZATION AGREEMENT* I Agree I understand that this is an educational consultation for the purpose of helping me improve my understanding of health and wellness. I understand this is not a medical diagnoses and that suggestions and information shared are not substitutes for medical care or ongoing medical care.*I understand that I am encouraged to consult a licensed physician for any concern, at any time, about any disease or pathology that currently exists or arises while as a client (ongoing consultations, coaching) and in general when using Elemental Alchemy services and resources. I Agree *Payment is expected to secure your appointment. If there is difficulty in making payment, please discuss other options before booking an appointment. Fees are accepted in the form major credit cards, PayPal, Venmo and check. Please make checks payable to Elemental Alchemy. I Agree *Individual appointments are scheduled for a specific time. You will be charged the full fee for missed individual appointments without at least 24 hours notice. Please do not use email to cancel or reschedule appointments but do so via the website’s scheduling system. I Agree *I have read and understood the above information and give my permission to begin working with Elemental Alchemy. I Agree Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Date of Birth* MM DD YYYY What are your top three mind-body health & wellness goals?Do you have any previous experience with Ayurveda? Yes or No? If yes, please list: What are hoping to learn, better understand and/or experience through Elemental Alchemy’s services?What health management tools or practices do you already use? (ie. taking supplements, listening to guided meditation or motivational podcasts, making healthy meals for yourself, reducing artificial sugars…)Amidst the pace of day-to-day life, what do you find yourself looking forward to? What currently brings you joy? Please describe:In your own words, what does “optimal health” feel like? Look like? Please describe: Aside from regular check-ups? Have you been under the care of a licensed health care provider in the past year? Yes No If yes, for what reasons? (Please include diagnosis and duration.) How have your health problems progressed since they began? Stable Gradually improving Rapidly improving Gradually worsening Rapidly worsening Not Applicable Please list current prescription and nonprescription medications (including vitamins & herbs): If yes, for what reasons? (Please include diagnosis and duration.) Is there any past medical history (i.e., illness, physical trauma, emotional stress, addiction) that will help to understand your current health condition and goals? Do you have any known allergies or intolerances? Yes No If yes, please list: How would you rate your energy level in general? Very High High Moderate Low Very Low During the day do you feel: Select All Engaged Excited Focused Lacking interest Irritated Unhappy Unmotivated Please describe the nature of your job including: general role/responsibilities; hours spent in the office, time spent working once home and on the weekends; and any work related stress: In general, how often do you feel stressed, rushed and/or behind? Always Most of the time Once in a while Never How regularly do you follow your ideal routine? Very regularly Somewhat regularly Irregularly Is the idea of a routine: Nice in theory but difficult to implement Uninteresting A foundation of your lifestyle How often do you exercise? Daily Weekly Seldom At what time of day do you typically exercise?Please specify type of exercise, duration & intensity: What do you currently do or would like to do to alleviate stress? Please describe.At what time do you prefer to wake up? At what time do you usually go to bed?What time to do turn off screens?How many days a week do you rely on an alarm to wake you?Do you have a different sleep schedule on weekends? If so, on free days what time do you go to bed? What time do you wake up?How do you generally feel upon waking? Fresh & rested A little tired Moderately tired Very tired Please mark all that describe the your sleep quality: Restful Deep Light Fall asleep quickly Easily awakened (“light sleeper”) Difficulty falling asleep Difficulty waking up On nights when you stay up later than your ideal, it’s usually because: You get a second wind after 10pm You’re trying to cross off more things from your to-do list You’re out with friends When you have a bad night’s sleep, your biggest challenge is that you feel: Spacey, exhausted Irritable, “off your game” Groggy At what time do you eat your first meal of the day?Which is your biggest meal? Breakfast Lunch Dinner At what time do you eat your final meal of the day?How much of your daily intake occurs after 6pm?How’s your digestion? Good Fair Poor If applicable, please describe any digestive discomfort you experience: How much water do you drink per day? 1-2 glasses 3-5 glasses 7+ glasses How often do you drink caffeine? Never 1 cup daily 2-3 cups daily 3-4 cups daily Are there particular foods that cause discomfort when you eat them? Yes or No? If yes, please list: What do you eat on a typical weekday? How is it different on weekends? (Describe) Ayurveda understands that an individual’s level of reproductive system and sexual activity affects overall well being as much as proper diet and proper sleep. That said, please only answer what you feel comfortable disclosing.Please mark any symptoms you are currently experiencing: Vaginal dryness Painful urination Recurring yeast infection Pain during intercourse Excessive discharge Low libido If applicable, age of your first menstruation:Which of the following describes your menstruation: Irregular cycle Absent or missed cycles Normal flow Heavy flow Light flow Scanty/spotty flow Ceased (menopause) Birth control If taking birth control, please include type & duration: Do you have any associated symptoms (before or during menstruation)? Pain/cramping Fluid retention Acne Mood swings Depression Other Do you have a history of pregnancy, miscarriages, abortions or complications related to pregnancy or delivery? If yes, please explain: How often do you engage in sexual activity? (include partner & self) Daily Weekly Monthly Seldom Choose not to answer Feel free to share any additional information including comments, more detailed answers, etc.“Data submitted by this form will be used by Elemental Alchemy, LLC and no other entity or individual.” description here Δ