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Julie Ann Wardwell ‐ Clinical Ayurveda Specialist Cell (508) 287‐3161, Fax (508) 744‐6654
CONFIDENTIAL CLIENT HISTORY
Telephone – Home: ______________________ Cell: ____________________________
Birth date: ______________ Age: _________
Partner status: ____________________# of children: _____ Ages: __________________
Referred by: _____________________________________________________________
1. Please check the items that reflect your main objectives:
□ I want a holistic approach to my health and managing illness and dis-ease.
□ I want to improve my general health and wellness and reduce my vulnerability to
illness and disease
□ I want to improve my lifestyle and dietary practices to improve my health
□ I want to change my habits and behavioral patterns to improve my relationships with
□ I want to manage stress, tension and worry to attain a more stable emotional nature
2. What do you want to achieve or change in terms of your health and wellness?
3. How would your life be different if you were to achieve these objectives to your
REVIEW OF CURRENT CONCERNS
4. What are your major health concerns?
5. When did this begin?
©2009 Chalice Well Ayurveda, Cape Cod, MA. Page 1
Page 2 . Have you had a diagnosis? If so. for what reasons: _______________________________________________________________________ _______________________________________________________________________ 10. Cape Cod.org ©2009 Chalice Well Ayurveda. how was it arrived at. Julie Ann Wardwell ‐ Clinical Ayurveda Specialist Cell (508) 287‐3161. ________________________________________________________________________ ________________________________________________________________________ PAST HEALTH CONDITIONS 13. Fax (508) 744‐6654 6. Are you currently receiving care from any other health professional? (Name)_________________________________________________________________ _______________________________________________________________________ 9. Operations/dates: ________________________________________________________________________ ________________________________________________________________________ www. MA. Other Significant Symptoms: ________________________________________________________________________ ________________________________________________________________________ 12. massage therapist or acupuncturist? □ Yes □ No Name: __________________________________________________________________ 11.If so. Serious illnesses/dates: _______________________________________________________________________ ________________________________________________________________________ 14. Has anything recently changed or become worse? ________________________________________________________________________ ________________________________________________________________________ 7. Do you see a chiropractor. what was it. Have you been under the care of a licensed health care practitioner in the past year? □ Yes □ No . and by whom? ________________________________________________________________________ ________________________________________________________________________ 8.chalicewellayurveda. Hospitalizations/dates: ________________________________________________________________________ ________________________________________________________________________ 15. Other Diagnosed conditions and date of diagnoses.
org ©2009 Chalice Well Ayurveda.chalicewellayurveda. Page 3 . I F Diarrhea Loose stools Blood in stool Regular elimination I Black stool Heavy stool Mucous in stool Slow to pass stool Pass stool only after eating a meal Light stool Weight gain abdominal Weight gain hips and thighs www. Frequency 1 = Daily 2 = Several times per week 3 = Several times monthly Intensity 1 to 3 = Mild discomfort 4 to 6 = Moderate discomfort 7 to 10 = severe discomfort Digestion F I Gas – Non odor Belching Bloating Food cravings F I Gas with odor Heartburn Acid Reflux Sores on tongue or inside mouth Ulcers Excessive appetite Loss of taste Food allergies Abdominal pain Variable appetite F I F I Nausea after eating Vomiting Difficulty swallowing Heaviness after eating Sleepy after eating No feeling of hunger Elimination F Constipation Dry stools Rectal pain Irregular elimination Food particles in stool Weight loss more than 5lbs. MA. Cape Cod. Fax (508) 744‐6654 Height __________ Current weight__________ Desired weight _________ Weight 1 month ago__________ Weight 1 year ago__________ Health Concerns or challenging symptoms Please check off any symptoms that you are currently experiencing. Julie Ann Wardwell ‐ Clinical Ayurveda Specialist Cell (508) 287‐3161. Even if the symptoms are mild. This information will explain how your mind and body reacts.
Fax (508) 744‐6654 Neuropsychology F I F I Worry Anxiety Overwhelm Feeling spacey Indecisive Poor memory High stress levels Dizziness Irritable Anger Rage Resentment Jealousy Envy Critical of others Lethargy Sadness Depression Greediness Over attachment Grief Procrastination Critical of self Seizures Headaches Intense thinking Sharp responses Difficulty concentrating Poor mental clarity Changing emotions F I F I F I F I Skin.chalicewellayurveda. and Throat F Jaw pops or locks Grinding teeth I F Tooth decay Mucous in throat or post nasal drip Chronic clearing of throat Frequent colds Bleeding gums Bad breath Tonsils removed Loss of smell Canker sores Nose bleeds Deviated septum Nose bleeds I Facial pain Swollen glands Chronic Sinus congestion Cold sores Allergic rhinitis Sore throat Burning sinuses www. Nose. Hair. Page 4 . MA. Julie Ann Wardwell ‐ Clinical Ayurveda Specialist Cell (508) 287‐3161. Cape Cod. and Nails F I Dry skin Itching Rashes Hives Bruise easily Change in texture Nails that chip or crack F I Oily skin Hair loss Eczema Psoriasis Dandruff Poor healing sores Acne red pimples Acne white pimples Acne black pimples Moles Brown spots Excessive sweating Nails with white spots Nail fungus Ears and eyes F I Poor Hearing Ear Pain Ear infections Ringing in ears Dizziness F I Dry eyes Red eyes Watery eyes Spots or tracers Light sensitive Eye pain Dark circles Near or Farsightness Astigmatism Glaucoma Head.org ©2009 Chalice Well Ayurveda.
Julie Ann Wardwell ‐ Clinical Ayurveda Specialist Cell (508) 287‐3161.chalicewellayurveda. Fax (508) 744‐6654 Cardiovascular F I Cold hands Cold feet F I Low blood pressure High blood pressure Angina Anemia Intolerance to heat or cold Fainting Chest pain Irregular heart beat High cholesterol Arteriosclerosis or Hardened arteries Arthrosclerosis or blocked arteries Heart disease Heart murmur Heart attack Heart surgery Stroke F I F I F I F I Respiratory F I Dry cough Brown or gray phlegm Pain on breathing Shortness of breath without exertion F I Coughing blood Yellow or green phlegm Bronchitis Moist cough White phlegm Asthma Difficulty breathing while lying down Asthma while exercising Urinary F I Painful urination Urinary urgency Frequent urination Inability to hold urine Dark yellow or brown urine F I Blood in urine Kidney infections Bladder infections Kidney stones Decreased flow Increased flow Slow to start Awaken more than once during the night Clear or mucousy Sweet smell Bright yellow strong odor Musculoskeletal F Neck Pain Back Pain Joint pain Foot pain I F Sore muscles Weak muscles Stiff muscles Cramping muscles I Hot or swollen joints Arthritis Bone loss Reduced range of motion www. Page 5 . Cape Cod.org ©2009 Chalice Well Ayurveda. MA.
Fax (508) 744‐6654 Female Reproductive F Irregular cycles Heavy bleeding Prolonged bleeding Spotting mid cycle Unusual bleeding or clots Fibroids I F Menstrual cramps Menstrual bloating Painful breasts I F Water retention Painful intercourse Vaginal dryness Hot flashes Night sweats Infertility Irritability Yeast infections Ovarian Cysts Breast lumps or cysts I Female Reproductive Is there a possibility that you are pregnant?_____________________________________ Age at first menses? _______________________________________________________ Date of last PAP smear? _______________________Breast exam?__________________ Are you on birth control?____________________Type?__________________________ Do you keep track of your menses on a calendar? ________________________________ # of Pregnancies?___________Miscarriages?___________Premature births?__________ Onset of Menopause?__________________Are you taking HRT?___________________ Describe your menstrual pattern. a person’s level of sexual activity impacts health and well-being in the same way as other aspects of daily life—such as diet or sleep. Julie Ann Wardwell ‐ Clinical Ayurveda Specialist Cell (508) 287‐3161. Regularity: Irregular____Variable______Regular____________________ Quantity of flow: Variable_____Light_____moderate______Heavy______ Level of discomfort: Painful________Mild Pain_______Painless_________ Length of cycle: # of days?_______ Describe any gynecological problems: ________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Sexual Activity According to Ayurveda. describe pattern when still menstruating.chalicewellayurveda.org ©2009 Chalice Well Ayurveda. MA. 16. Is your current sexual activity satisfactory? __________________________________ www. How often do you engage in sexual activity? Include with or without a partner. Cape Cod. If menopausal. Daily_____Several times per week_____Several times per month_____Not at all______ 17. Page 6 .
org ©2009 Chalice Well Ayurveda. Do you have any specific spiritual practices now? Please describe _______________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ www. Cape Cod. when did you quit? ____________________ 22. Fax (508) 744‐6654 Lifestyle Activities 18. Page 7 .)? Please explain: ___________________________________________________________ _______________________________________________________________________ 24. How much of the following do you drink?: (Indicate number of 8 ounce cups per day) □ Plain water: _______ □ Caffeinated Coffee: _______ □ Decaf coffee: _______ □ Herbal Tea: _______ □ Caffeinated tea: _______ □ Decaf tea: _______ □ Juice: _______ □ Soda: _______ □ Soy milk: _______ □ Cow milk: _______ □ Grain or nut milk: _______ □ Other: _______ 20. Do you drink alcohol? _____________________________________________ If yes. Do you currently smoke? ______________________________________________ How many cigarettes per day? _______How long have you smoked?_______________ Have you ever smoked? □ Yes □ No If yes. etc. how often □ daily □ several times weekly □ several times monthly □ seldom I usually choose: □ beer □ red wine □ white wine □ sweet or hard liquor 21. Do you experience allergic reactions to any substances (food. What country/countries are your ancestors From?_____________________________ ________________________________________________________________________ 28. Are you currently experiencing stress in any other close relationship?_____________ Level of stress: (please circle): 1 2 3 4 5 Level of satisfaction: 1 2 3 4 5 27. Please describe your primary intimate relationship: Level of stress: (please circle): 1 2 3 4 5 Level of satisfaction: 1 2 3 4 5 26. 5 = most): Level of stress: (please circle): 1 2 3 4 5 Level of work satisfaction: 1 2 3 4 5 25. MA. Do you exercise regularly? ______________________________________________ Length of time: __________________ Times per week: __________________________ Type(s) of exercise: _______________________________________________________ 19. Please describe your work life (1 = least. when? ___________ 23. environmental.chalicewellayurveda. Julie Ann Wardwell ‐ Clinical Ayurveda Specialist Cell (508) 287‐3161. Any current or past use of addictive substances and recreational drugs? __________ Substance: _________________Amount: ______________ If quit.
At end of day: Do you have enough energy to do what you want to do? □ Always □ Most days □ Half the time □ Rarely □ Never 32. Do you go to bed at a regular time? Do you sleep through the night? How many times do you wake up to go the bathroom? What time do you wake up in the morning. Do you have insomnia? How Often? ________________________________________________________________________ ________________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Dietary Patterns Meal Time of day List Typical foods and beverages Breakfast Snacks Lunch Snacks Dinner Late Night www. How many hours of sleep do you get in 24 hours?_____________________________ 30.chalicewellayurveda. Describe your sleep patterns.org ©2009 Chalice Well Ayurveda. Fax (508) 744‐6654 ________________________________________________________________________ 29. Cape Cod. Page 8 . Do you feel refreshed upon awakening? □ Always □ Most days □ Half the time □ Rarely □ Never 31. MA. Julie Ann Wardwell ‐ Clinical Ayurveda Specialist Cell (508) 287‐3161.
Do you eat for emotional reasons? ________________________________________ Food choices: ____________________________________________________________ 34. Do you graze. Page 9 . Cape Cod. Any current or past eating patterns or any other food related issues?______________ Describe: _______________________________________________________________ Time of day Describe Daily Activities and Environment Awaken Activities Breakfast Activities Lunch Activities Dinner Activities Bedtime List any other information you think may be important. sit in silence before your meal. MA. for example have a jar of nuts at your desk at work and eat them throughout the day? _________Food choices for grazing:__________________________ ________________________________________________________________________ 35. etc. Julie Ann Wardwell ‐ Clinical Ayurveda Specialist Cell (508) 287‐3161. Fax (508) 744‐6654 33.org ©2009 Chalice Well Ayurveda. Do you have any routines around eating (say grace.)? Please explain: ______________________________________________________ 36. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ www.chalicewellayurveda.
and supplements What medications. Relation Father Age Health problem Mother Sister Brother Children www. If the family member is deceased. herbs. herbs. or supplements are you currently taking? Please include significant remedies that you have recently stopped taking. Fax (508) 744‐6654 ________________________________________________________________________ ________________________________________________________________________ Current medications. MA. Substance For each substance. Please also include birth control and hormone replacement therapy.org ©2009 Chalice Well Ayurveda.chalicewellayurveda. Self Chiropractor Taken for what purpose? Taken for how long? What is your current dosage? What have been the benefits? Family Medical History Please complete this section only for family members with particular health problems. please list age at death & cause of death. indicate if over-the counter OTC or prescription Prescribed by whom? MD. Page 10 . Cape Cod. Julie Ann Wardwell ‐ Clinical Ayurveda Specialist Cell (508) 287‐3161.
we recommend that you receive a proper evaluation. As part of the Initial consultation we may take your blood pressure and vital signs. Its practice was formally legalized under the passage of Senate Bill 577 in January 2003. Patient's Signature: ___________________________________________ Today’s Date: ________________________________________________ www. If you are suffering from a disease or symptom that has not been evaluated by a Medical Doctor or another licensed health care professional. Fax (508) 744‐6654 Informed Consent and Disclaimer A Clinical Ayurveda Specialist is not trained in Western diagnosis or treatment and will not make suggestions about altering your medical care or medications. If during the examination. any findings are suggestive of a possible medical imbalance we will refer you to a Medical Doctor for further evaluation.org ©2009 Chalice Well Ayurveda.chalicewellayurveda. In the United States . Cape Cod. This examination does not take the place of a medical evaluation. Ayurveda is a non-licensed profession. Julie Ann Wardwell ‐ Clinical Ayurveda Specialist Cell (508) 287‐3161. we are evaluating our findings from an Ayurvedic perspective only and not from a Western medical perspective. MA. By signing below. you give your permission to Chalice Well Ayurveda to begin a program of Ayurvedic health care with a Clinical Ayurveda Specialist. and perform some examination techniques similar to a routine medical examination. Page 11 .
color therapy. Each individualized treatment program is formulated by a Clinical Ayurveda Specialist who has completed 1800 hours of training. massage therapy. frequent regular follow-up visits are recommended over a six. In order to successfully implement these Ayurvedic principles into your life. Page 12 . and Yoga Sadhana and Pancha Karma training from the California College of Ayurveda. herbs. The goal of all Ayurvedic programs is to create within your body and mind an optimum environment for healing to take place and to maximize your body's ability to heal itself. sound therapy.org ©2009 Chalice Well Ayurveda.chalicewellayurveda. Your program may include lifestyle adjustments. plus an additional 600 hours of Advanced Ayurveda Herbalism. Originating in ancient India. Patient’s Signature: __________________________________________ Today’s Date: ______________________________________________ www. MA. Fax (508) 744‐6654 WHAT TO EXPECT FROM YOUR AYURVEDIC HEALTH CARE Ayurveda is a natural healing system that has been successfully practiced for thousands of years. The healing programs are time-honored principles that focus on understanding your particular body-mind constitution and the unique nature of your imbalance. Julie Ann Wardwell ‐ Clinical Ayurveda Specialist Cell (508) 287‐3161.to twelvemonth period. aroma therapy. Cape Cod. dietary changes. and other natural therapeutics. this medical tradition states that each person’s path toward optimal health is unique--because each person is unique.