Consultation
  1. Name
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  2. Address
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  3. City
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  4. State
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  5. Zip Code
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  6. Country
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  7. E-mail(*)
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  8. Home Phone
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  9. Wk/Cel
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  10. Marital Status





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  11. Birth Date
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  12. Birth Time (10:00) AM
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  13. Birth City
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  14. Birth State
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  15. Birth Country
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  16. Age of Physical Body
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  17. Weight
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  18. Height
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  19. High School
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  20. College
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  21. Graduate
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  22. Referred By
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  23. Physician
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  24. Reason for Your Consultation/ Please number each reason in order of importance
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    For serious diseases or chronic health issues give specific details such as date of first occurrence and related symptoms or surgeries performed
  25. SpecificArea of Body that is an issue
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    List specific areas (if any) where you are feeling pain or discomfort from injury, stress or trauma. Mention the muscle or region
  26. Childhood Diseases
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    List any serious childhood diseases
  27. Medications/Supplements
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    List all medications / Health supplements / Herbs, you are currently taking (List time period and for what purpose)
  28. Do you have any addictions to Coffee, Black Tea, or Cigarettes or Drugs?


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  29. If Yes, how often, and for how long has this been a habit?
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  30. List any genetic or hereditary diseases from specific family members
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  31. Do any family members have addiction problems (e.g., alcohol, drugs)? If yes, who?
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  32. Did you experience any emotional abuse in your life?



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  33. Current Career/Job
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  34. Career/Job satisfaction



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  35. Family/Social life



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  36. How would you best describe your digestive system? Choose the best answer you are currently experiencing.










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  37. How often do you experience the above?



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  38. How often do you have a bowel movement?




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  39. Stool



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  40. What time do you usually go to sleep?
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  41. What time do you usually wake up?
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  42. Sleep



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  43. If your sleep is interrupted, what time do you wake up at night?
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  44. Dreams



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  45. State of Mind



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  46. Memory



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  47. Activity & Excercise



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  48. How many times per week do you exercise (yoga, sports, gym etc…)
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  49. How many times per week do you perform cardiovascular exercise?
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  50. Sweat/Perspiration



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  51. Body Weight



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  52. Has your weight ever fluctuated (up or down) more than 15-20lbs?


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  53. Appetite



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  54. How many meals do you eat per day?
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  55. Are you a Vegetarian?


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  56. If no, how often do you eat meats?



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  57. Thirst



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  58. Taste (What you like to eat the most, Which taste do your crave most often



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  59. Speech



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  60. Is your life spiritual? Explain:
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  61. Faith



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  62. Emotional Temperament



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  63. Is your life purposeful? (Goals, direction)
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  64. How often do you practice any type of yoga and ayurveda (postures, breathing, mantra disciplines, meditation, service to others, contemplative hiking, gardening or nature dwelling)?




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  65. Any additional thoughts or comments you feel will be supportive to this consultation
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  66. (*)
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