Ayurvedic Initial Consultation FormPlease complete the form below BEFORE of your appointment if this is your first session with Emma. Name * First Name Last Name Date of Birth MM DD YYYY Gender * Occupation * Marital status * Children (names and ages) If applicable Address * Phone number * Energy levels * Appetite * Sleep onset * Sleep quality * Bowel movements * Description and when / how many times a day? Stool * Urination * How many times a day / night? Colour of first urination of the day? Alcohol and drug use * Which substances, if any, and quantity per week? Smoking * If yes, average quantity per day? Exercise * Activities and durations on average Activities and interests * Menstrual cycle If applicable, regular or erratic? How many days in cycle? How many days of menstruation? Pains or other symptoms? Type of delivery If complications, please expand Chief complaint / presenting complaints * History of present illness(s) * History of any past illnesses Family history Illnesses or conditions on mother's side Illnesses or conditions on father's side Diet * Please describe a typical daily intake Favourite foods * Fluids * Please describe a typical daily intake Current medication Previous experience with Ayurveda If you have had a consultation before or worked with Ayurvedic medicine, please describe your experience. Intentions * What you hope to experience from Ayurveda? Declaration & Informed Consent * Please ensure you have read our Terms & Conditions and Privacy Policy (in the footer below this form) I have been informed of the Beinspired Ayurvedic Process and am willing to proceed The above information is correct and complete. I consent to these details being kept securely and confidentially I am aware that I can ask to view my details at any time I am aware I can withdraw consent at any time and ask for my data to be destroyed I am aware that my data will be destroyed once I cease to attend sessions Thank you for completing the consultation form. I look forward to seeing you soon for your appointment.