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Thank you
for taking time to fill this out before your appointment, so that once we are in-person we can really start going beyond the symptoms and looking more deeply into the underlying inner state of body-mind-spirit.
Ayurveda Form - Please fill out 24 hours prior to your appointment
*
Indicates required field
Name
*
First
Last
Email
*
Reason for Followup {more details can be given below}
*
I have been following the recommendations and feel ready for the next phase
It's a new season and I would like some seasonal recommendations
It has been a long time and I want to check in and re-group
Other {explain below}
Check one
Please update me on your health concerns, symptoms and goals
*
Any changes or improvements since our last appointment?
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Was any one thing {or more} of my recommendations particularly helpful?
*
Were there recommendations that you had trouble pursuing and need more help or motivation with?
*
Areas where you would like additional support?
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I would like support on Digestion / Elimination
I would like support on skin
I would like support with pain (eg. join, back, headaches)
I would like herbal support
I would like food support
I would like to resolve mind and emotional blockage
I would like yoga support
I would like Sleep Quality support
I would like Pregnancy / Postpartum support
Other
Check all that apply
Anything you can add about the above?
*
My digestion
*
I'm hungry all the time
I'm rarely truly hungry
My hunger varies
After meals I feel tired, heavy, lethargic
After meals I feel light and energized
After meals I feel indigestion / belching
After meals I feel bloated / gassy
Check all that apply
My elimination
*
Floats
Sinks
Well formed (banana shaped)
Loose
Dry / Hard
1x a day
More than 3x a day
I skip days
Dark brown color
Yellow color
Whitish mucous in stool
Check all that apply
My sleep
*
Trouble falling asleep
Trouble staying asleep
Wake up with anxiety or strategizing
Restless dreaming
Sleep is great
I wake up rested and ready for the day
I wake up resisting the day and tired
Check all that apply
Check all that apply
*
Fatigue
Dryness {hair, nails, skin, stool}
Low appetite
Nausea
Low stamina
Skin issues
Redness in eyes or anywhere on body
Emaciation
Excessively flexible joints
Swollen glands
Feeling like muscles are heavy
Excess food cravings
Overweight
Excess weight in one area of the body
Pain in bones / joints
Dizziness
Weakness in bones
Pain in abdomen
Low sex drive / loss of vitality
Dark circles around eyes
Excess sexual desire
Irritability
Hypersensitivity
Depression
Anxiety
Insomnia
You can expand below.
Expand on the above, or anything else I should know?
*
Submit
About
SRY
Online Followup for Teachers
Online Followup for Teachers
Audio SRY Practice with Kaya
SRY Fundamentals Course
Sharing SRY
Agni and Soma Home Study
YTT in SRY
Ayurveda
Join Agni and Soma Nutrition
Tridoshic Food List
Ayurveda Application
Ayurveda Followup
Yogify
Māyurveda
Māyurveda Intake
Early Pregnancy
Mayurveda Conception Client Pages
Māyurveda Prenatal Client Pages
Mayurveda Postpartum Pages
>
Kids Ayurveda
Work with Me
Retreat Intake
Training / Mentoring Intake
One on One Intake
Audio
Shavasana
Bhagavad Gita Essentials
Contact
Resources