New Client Form

Please fill out complete ALL fields

Name*
First Last
Date*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Occupation*
Doctor*
Please describe your present health concerns and their duration.*
Please describe your present health concerns and their duration.*
Age*
Weight*
Height*
Other than routine checkups, ate you seeing a physician or any other health care professional?*
- Yes
- No
If Yes, explain*
Please list medications/herbs/supplements.*
Do you have any past medical history? If yes, specify age of occurrence, duration and treatment*
Are you allergic to any substances? Please specify.*
Health as a child*
- Good
- Fair
- Poor
How do you rate your energy level?*
- Very high
- High
- Moderate
- Low
- Very Low
Sleeping
What time do you wake up?*
What time do you go to bed regularly?*
DO you sleep in the daytime?*
- Yes
- No
How do you generally feel upon rising in the morning.*
- Fresh and rested
- Little tired
- Moderately tired
- Fairly tired
How is your sleep*
- Sound, normal duration
- Too heavy and or too long
- Difficulty waking up
- Light, interrupted
- Difficulty Falling asleep
- Awaken too early
- Too little sleep
- Fairly tired
- Nightmares
Natural Urges*
- Bowel Movements
- Breathing
- Thirst
- Gas
- Burping
- Urination
- Sneezing
- Semen
- Sleep
- Yawning
- Hunger
Do you delay or suppress any of the following?
Urination*
- Pain
- Burning
- Discoloration
- Frequent urination during the day
- Other discharges
- Urination several times during the night
Do you have any of the following urinary problems?
Bowel Movements*
- Once every 2 to 3 days
- First thing in the morning
- Need a laxative daily
- Once daily
- Late in the day
- 2-3 times a day
- Immediately after meals
- Other
Bowel Nature*
- Soft
- Medium
- Hard
Emotions
What is your present state of mind and emotions?*
- Good
- Fair
- Poor
How are your family relationships?*
- Excellent
- Good
- Fair
- Poor
How is your social life?*
- Excellent
- Good
- Fair
- Poor
How is your mental status?*
- Excellent
- Good
- Fair
- Poor
How is your career?*
- Excellent
- Good
- Fair
- Poor
How purposeful is your life?*
- Excellent
- Good
- Fair
- Poor
Rate your spiritual life?*
- Excellent
- Good
- Fair
- Poor
As a child, did you experience abuse or trauma?*
- None
- Emotional
- Physical
- Sexual
- Verbal
Daily Routine
Daily Routine*
- Very regular
- Somewhat regular
- Irregular
Do you practice any type of mediation?*
Do you practice yoga?*
Do you exercise?*
- Yes
- No
Pace*
- Vigorous
- Moderate
- Gentle/Light
If yes, What kind? How often? How long?
Do you travel a lot?*
- Yes
- No
Do you smoke or others?*
- Yes
- No
If yes, How much a day?
Do you drink alcohol?*
- Yes
- No
If yes, how much a day/week?
Do you drink coffee?*
- Yes
- No
If yes, how many cups a day?
Which type of weather makes you feel most uncomfortable?*
- Cold
- Hot
- Cool and damp
- Humid
Meals
What taste(s) do you like or crave?*
- Sweet
- Sour
- Salty
- Bitter/Astringent
- Hot/Spicy
- Starches
- Oily
Are there any foods that create discomfort when you eat them?*
- Sweet
- Sour
- Salty
- Bitter/Astringent
- Hot/Spicy
- Starches
- Oily
Do You Eat the Following Foods?
Grains/cereals*
- Daily
- Weekly
- Monthly
- Never
Vegetables*
- Daily
- Weekly
- Monthly
- Never
Fruits*
- Daily
- Weekly
- Monthly
- Never
Dairy*
- Daily
- Weekly
- Monthly
- Never
Eggs*
- Daily
- Weekly
- Monthly
- Never
Poultry*
- Daily
- Weekly
- Monthly
- Never
Meat*
- Daily
- Weekly
- Monthly
- Never
Seafood*
- Daily
- Weekly
- Monthly
- Never
Sugar/Honey*
- Daily
- Weekly
- Monthly
- Never
Desserts*
- Daily
- Weekly
- Monthly
- Never
Juices*
- Daily
- Weekly
- Monthly
- Never
Please explain your typical meals.
Breakfast*
Time*
Lunch*
Time*
Dinner*
Time*
Snacks
Time
Which is your main meal?*
How much water do you drink a day?
Eating Habits Include*
- eat with full attention on food
- never sit to eat
- talk of converse a lot while eating
- eat fast
- watch TV
- quietly/relaxing atmosphere
- multi-tasking
- other
If other please explain
Rate your digestion*
- Good
- Fair
- Poor
Is there other information you would like to provide concerning your meals and/or digestion?*
This information will help determine your constitution. When answering these questions, go as far back as you can remember to your youth and adult years. You want to identify those characteristics you were born with. Generally, pick one per category (though in some there may be more than one). Check off and add up your score at the bottom.
Mental Profile
Mental Activity*
- Quick, active, restless
- Sharp, critical, aggressive
- Calm, steady, slow, stable
Memory*
- Short term
- Generally good
- Good long term
Concentration*
- Weak
- Generally good
- Very good
Ability to Learn*
- Quick to grab concepts
- Moderate ability to grasp new infrormation
- Slow to grasp new information
Dreams*
- Fearful, very active, flying
- Aggressive, fiery, adventurous
- Watery, romance, relationships
Sleep*
- Light, interrupted
- Sound, medium
- Sound, heavy, long
Speech*
- Quick, can miss words
- Sharp, direct, strong
- Slower, clear, melodious
Voice*
- High pitched
- Medium pitched
- Low pitched
Behavioral Profile
Eating Speed*
- Fast
- Medium
- Slow
Hunger Level*
- Irregular
- Sharp, can be strong
- Can easily miss meals
Food/Drink*
- Prefers warm
- Prefers cold
- Prefers dry and warm
Achieving Goals*
- Easily distracted
- Focused and driven
- Slow and steady
Giving/donations*
- Gives small amounts
- Gives nothing or large amounts infrequently
- Gives regularly and generously
Relationships*
- Many casual
- Intense
- Long and deep
Sex drive*
- Variable, low
- Moderate
- Strong
Works best*
- Supervised
- Aone
- In groups
Weather preference*
- Warm and moist
- Cool and dry
- Warm and dry
Reaction to stress*
- Excites quickly
- Medium
- Slow to get excited
Financial*
- Don't save, spends quickly
- Saves but big spender
- Saves regularly, accumulates
Routine*
- Dislikes routine
- Likes organizing and planning
- Works well with routine
Emotional Profile
Moods*
- Changes quickly
- Changes slowly
- Steady, unchanging
Reacts to stress with*
- Fear
- Anger
- Indifference
More sensitive to*
- Own feelings
- Not sensitive
- Others feelings
When threatened tends to*
- Run
- Fight
- Make peace
Relations with spouse/partner*
- Clingy
- Jealous
- Secure
Expresses affections*
- With words
- With gifts
- With touch
When feeling hurt*
- Cries
- Denial
- Inner confidence
Emotional trauma causes*
- Anxiety
- Denial
- Depression
Confidence level*
- Timid
- Outwardly self-confident
- Inner confidence
Physical Profile
Amount of Hair*
- Average
- Thinning
- Thick
Hair Type*
- Dry, frizzy, thin, dark
- Straigh, fine, premature graying
- Oily, wavy, thick
Hair color*
- Light brown, blond
- Auburn, reddish
- Dark brown, black
Skin*
- Dry, rough or both, dark/sallow, tans easily, cold
- Soft, normal to oily, light, sunburns easily, warm
- Oily, moist, fair, thick, cool
Complexion*
- Darker
- Pink, Red
- Pale-white
Eyes*
- Small, brown, gray, violet, unusual color
- Medium, green, hazel, almond shaped
- Large, dark, blue
Whites of eyes*
- Blue/brown
- Yellow or red
- Glossy/white
Teeth*
- Very large or very small
- Small-medium
- Medium-large
Weight*
- Thin, hard to gain
- Medium
- Heavy, easy to gain
Elimination*
- Dry, hard, thin, easily constipated
- Many during the day, soft to normal
- Heavy, slow, thick, regular
Sweat*
- Scanty
- Profuse
- Moderate
Statement of Understanding
I understand that Linda Tipke is an Ayurvedic Health Counselor and educator who provides me with information on the Ayurvedic approach to health care, which may affect my diet and health in a positive way. I understand that Linda Tipke is not a medical doctor or licensed medical practitioner, has not presented herself as such, and does not seek to diagnose, treat, or prescribe for disease, disorder or other pathological conditions. I agree that I am interested in enhancing my own abilities to heal and establish health in mind and body, and this is the reason I have sought these Ayurvedic consulting services. I agree that I may consult a licensed physician for any concern, at any time, about any disease or pathology that now exists or arises at any time during my professional relationship with Linda Tipke. Furthermore, I understand that Linda Tipke encourages regular medical checkups from a licensed medical professional of my choice, and that any medication that I am now taking upon my licenses physician’s advice, or will take in the future, is taken strictly according to my licensed physician’s directions. Furthermore, I understand that only a a licensed physician of my choice can advise me on medication dosages or the discontinuance or resumption of such medication. My signature below acknowledges the above statements, as fully read and understood.
Signature*
Date*
MM slash DD slash YYYY

New Client Form

Statement of Understanding