Wellness Consultation Client Form

Please complete Section 1 and 2 of this form at least 3 days before your consultation

Section 1

First Name

Last Name

Street Address

City

Postal Code / Zip Code

Province / State

Country

Email Address

Phone

May we send you text messages?

Yes No

Would you like to join our eNewletter to receive updates on classes, workshops, courses, upcoming events and tips and strategies from our Online Wellness Journal?

Yes No

What is your age?

Ayurvedic Astrology Consultation?

Yes No

Please give a brief description of your experience with Ayurveda

Please list three main reasons or issues for which you are seeking a consultation at this time

How would you describe your current state of health?

Physical

Mental

Emotional

Daily Routine

Upon Waking

Morning Routine

Daytime Routine

Evening Routine

Sleeping Habits

Average Sleep Routine

Characterize your average dream experience

Eating Habits

Breakfast

Lunch

Dinner

Snacks

Work Type

Work Schedule

Play

Exercise

Please share the general experience of your menstrual cycle each month.

Are you currently on any medications? If so outline what for, and how long you have been using consistently.

Are you currently using any recreational drugs? What? And Why?

Please note:

The information shared during your Ayurvedic Consultation is in no way to be considered as a substitute for a consultation with a duly licensed health-care professional.