Forms | Leela Ayurveda

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Please check the items that reflect your main objectives: Please note that Ayurvedic Consultations do not include medical diagnosis and treatments. If you are concerned about a medical condition or a latent or potential medical condition you should see a medical doctor.

Objectives

I would like an alternative approach to allopathic medicine for managing illness and disease

I would like to improve my general health, wellness and reduce my vulnerability to illness and disease

I would like to improve my lifestyle and dietary practices to improve my health

I would like to change my habits and behavioral patterns to improve my relationships with others.

I would like to manage stress, tension and worry to attain a more stable emotional nature

How would you describe your overall health at the moment?

Excellent

Good

Fair

Poor

Are you currently under a physician’s care for a specific medical problem? If yes, for what?

What are your present concerns and/or conditions that are currently bothering you, and how long?

What would you like to achieve or change in terms of your health and wellness?

Have you ever seen an Ayurvedic Practitioner?

Yes

If yes, when?

MEDICAL HISTORY

Are you currently under a physician’s care?

Yes

Are you currently taking any prescriptions?

Yes

If yes, please list prescriptions and dosages:

Are you currently taking any supplements/vitamins?

Yes

If yes, please list:

Do you have any allergies?

Yes

If yes, please list:

FEMALES ONLY

Are you currently pregnant?

Yes

If yes, how many weeks?

Number of previous pregnancies:

Difficult past pregnancies?

Pregnancy complications:

Are you currently pregnant?

Yes

If yes, how many weeks?

Do you use Birth Control?

Yes

If yes, what type and for how long?

How would you describe your cycle?

Regular

Irregular

How would you describe your flow?

Heavy

Medium

Light

Do you experience clotting?

Yes

If yes, when?

PMS Symptoms:

Any other symptoms during cycle:

Anything else you’d like to add about your reproductive health/concerns:

MALES ONLY

Prostate condition:

Other:

Please list any hospitalizations:

HABITS

Dietary preferences/restrictions:

Exercise habits, what kind, how often:

Caffeine use, what kind, how often:

Do you have a history of tobacco use?

Yes

If yes, how often?

Do you have a history of alcohol use?

Yes

If yes, how often?

Do you have a history of cannabis use?

Yes

If yes, how often?

Do you have a history of drug use?

Yes

If yes, how often?

Please indicate any other relevant medical history:

Have you experienced any weight changes in the last year?

Any recent or relevant life changes or stressors?

Please use this space to add any other information you’d like to share:

Check All That Apply To You Currently And Within The Last Six (6) Month:

Sweating

Scanty or no sweat

Excess

Profuse with body odor

Cold/clammy

I certify that the above information is correct to the best of my knowledge. I acknowledge I am responsible for payment of all services rendered.

Thanks for submitting!

SHIRODHARA: THIRD EYE OIL TREATMENT

SHIRODHARA: THIRD EYE OIL TREATMENT

MARMA CHIKITSA: AYURVEDIC ACUPRESSURE-ENERGY TREATMENT

MARMA CHIKITSA: AYURVEDIC ACUPRESSURE-ENERGY TREATMENT

NETRA TARPANA: EYE NOURISHMENT

NETRA TARPANA: EYE NOURISHMENT

BASTI

BASTI

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