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Client Intake – Mindful Mama Yoga & Ayurveda

Confidential

Mindful Mama Yoga & Ayurveda

Client History & Intake Form

Contact Information

Past Medical History Include dates and details

Family History Indicate family member

Current Digestive & Psychological / Emotional Health Challenges Check all that apply

Other Current Health Challenges

Health Goals

Health Habits

Diet Describe what is typical

Daily Routine

Enter your typical time, activities, and any variations for each part of the day.

Morning

Afternoon

Evening

Sex & Spiritual Practice Describe practice and frequency

Current Medications, Herbs & Supplements

Substance OTC / Rx Herb / Drug / Vitamin Prescribed By Purpose Duration Dosage Benefits / Side Effects

Notes

Informed Consent

All patients who participate in Ayurvedic health care through this program should be advised of the following:

  • Mindful Mama Yoga & Ayurveda is not a Medical Institute. Grace Kendrick is not trained in Western diagnosis or treatment and may not make suggestions about altering your medical care.
  • Grace Kendrick, CAS, is a Certified Ayurveda Specialist, a certified yoga teacher and the founder of Mindful Mama Yoga & Ayurveda. She is not a Medical Doctor.
  • If you are suffering from a disease or symptom that has not been evaluated by a Medical Doctor or another licensed health care professional, we recommend that you receive a proper evaluation and may provide you with a referral form.
  • Mindful Mama Yoga & Ayurveda will not recommend altering your prescriptions without the approval of your medical doctor.
  • While vital signs and some examination techniques similar to a routine medical examination will be performed, this evaluation is from an Ayurvedic perspective only. This examination does not take the place of a medical evaluation.
  • The practitioners in this office are not partners or otherwise affiliated in the same practice. Each practitioner is an independent practitioner and simply shares office space, equipment, and some support staff.

I have read and understand the above information and give my permission to begin a program of Ayurvedic health care with Mindful Mama Yoga & Ayurveda.

This form is confidential and protected under applicable privacy laws.

Ayurvedic History – Mindful Mama Yoga & Ayurveda
Mindful Mama Yoga & Ayurveda

Ayurvedic History

Constitutional Assessment

For each category, place an ✓ in the column that best describes your tendency over time.
Mark ? if unsure or if you wish to discuss with your practitioner.

Vata Pitta Kapha
Physical Patterns — Intake 7
Category Vata Pitta Kapha ?
Appetite My hunger level is variable, and I often forget to eat. I have a strong appetite and don't like to miss meals. I like to eat, but I can go without eating with no discomfort.
If I miss a meal, I often get light-headed, anxious or cranky. If I miss a meal, I often get irritable or angry. If I miss a meal, it doesn't really bother me.
I prefer to eat frequently with no set schedule, but often forget to eat. I prefer to eat 3 meals a day at about the same time. I rarely skip meals. I prefer to eat 2–3 times daily, but can go without eating.
Digestion After eating, I often experience gas or bloating. After eating, I often experience heartburn or acidity. After eating, I often feel heavy or sleepy.
Elimination I tend to have irregular bowel movements — one time per day or less. I tend to have 1–2 bowel movements daily, usually with regularity and ease. I tend to have one bowel movement per day with no straining or difficulty.
My bowel movements are often dry and hard. At times I may strain or push. My bowel movements are usually well-formed, but sometimes loose and may burn. My bowel movements are usually well-formed, slow and easy.
Weight I usually don't gain weight very easily. When I gain weight, it is easy to lose it. I gain weight easily and lose it slowly.
Body Temp. My hands and feet often feel cold, and I prefer warmer climates. I am warm most of the time, no matter what the climate is. I adapt easily to most conditions, but tend to feel cool.
Skin My skin tends to be dry. When very dry it tends to feel rough. My skin flushes easily and has a reddish or yellowish shade. My skin is thick, smooth and often feels damp or oily.
Sleep & Mental / Emotional Patterns — Intake 8
Category Vata Pitta Kapha ?
Sleep I tend to sleep lightly and awaken very easily. It can be difficult for me to fall asleep. I tend to sleep soundly and awaken with ease. My sleep tends to be deep and long. It can be difficult for me to awaken in the morning.
Stress Under stress I often become worried or overwhelmed. Under stress I often become irritable, but usually rise to the challenge. Under stress, I often withdraw to observe or become reclusive.
Decisions I am changeable and often have difficulty making decisions. I make decisions easily, but can change my mind with new information. I am careful but easy-going about decisions.
Projects I like to start projects, but at times have difficulty finishing them. I like to start and finish projects. Completion is important to me. I like working on a project, but prefer to let others start them.
Personality When balanced I feel creative, enthusiastic, and vivacious. When balanced I feel perceptive, disciplined, and logical. When balanced I feel nurturing, calm, and devotional.
For Women Only
Category Vata Pitta Kapha ?
Cycle My menstrual cycle is irregular. It comes every ___ to ___ days and lasts ___ days. My menstrual cycle is regular. It comes every ____ days, and lasts _____ days. — (same as P, please note pattern)
Flow My menstrual flow is often light, but may vary. My menstrual flow is medium heavy, and is usually consistent. My menstrual flow is heavy and very consistent.
Pain I often have severe, cramping pain during menses. At times, I have mild pain during menses. I rarely have pain during menses.
Running Totals
Vāta
Checks0
Pitta
Checks0
Kapha
Checks0

Prakruti — Practitioner Use Only

V ___ P ___ K ___

Vikruti — Practitioner Use Only

V ___ P ___ K ___
Mindful Mama Yoga & Ayurveda  ·  Ayurvedic History — Constitutional Assessment