Email

Referred by

Parent | Guardian

Age

Weight

Height

Number of children

Number of siblings

Please list current complaints in order of severity.

Complaint + for how long.

Other, please explain.

Select your level of stress you are experiencing on a scale of 1 to 10.

1 being low, 10 being high.

Have you had an unintentional weight los of gain of 10 lbs. or more in the last 3 months?

Please list any medications you are currently taking and what it is for.

Please list any major hospitalizations, injuries, surgeries, illnesses or car accidents.

Please include the year, procedure and outcome of each.

Family History: Did your mother, father, siblings or grandparents have any of the following:

Diabetes, heart disease, cancer, back pain or headaches.

Please list quantities of any boxes selected above.

Other, please explain.

Please explain any dosages or specifics here.

Patient Record of Disclosures

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual's home.

Please contact me with protected health information in the following manner. (This does not include appointment confirmation calls or other general information. Select one:

The Privacy Rule generally required healthcare providers to take reasonable steps to limit the use or disclose of, and request for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses of disclosures made pursuant to an authorization requested by the individual. Note: Uses and disclosures of information may be permitted without prior consent in an emergency.

Ayurvedic Intake Form