ࡱ> IKFGH Sbjbj,(,( JNBNB5q/"""8Z"Veh"#"#:\#\#\#D)D)D)ddddddd,hpkdD)2(D)D)D)dn.\#\#en.n.n.D)\#\#dn.D)dn.n.E]h!c0$\*M`Jd&e0Ve`ln.l!cn.!c5cD)D)D)ddn.D)D)D)VelD)D)D)D)D)D)D)D)D) d:    (PLEASE WRITE NEATLY IN BLACK INK ONLY) Appointment Date & Time: ________________________ Intern Name: ____________________________  INFORMED CONSENT To authorize Complementary or Alternative Health Care  (2) FAMILY HISTORY Indicate what members of your immediate family have had these conditions. (Go back one generation) (If adopted, answer according to family heritage, if known.) ( High Blood Pressure ( Heart Disease ( Other ( Cancer ( Mental Disorder __________________ ( Stroke ( Diabetes ____________________ (3) ALCOHOL, TOBACCO AND Substance USE Practitioner Notes: a. Do you drink alcoholic beverages? ( Yes ( No If yes, how often: ( Daily ( Several times weekly ( Several times monthly ( Seldom I usually choose: ( beer ( wine ( sweet or hard liquorb. Have you ever smoked tobacco? ( Yes ( No If yes, how much per day?___________ If you have quit smoking, when did you quit? ______________________________________c. Any current or past use of addictive or habitual substances? ( Yes ( No (Note: This will be kept confidential) Please list all substances (either current or long-term past usage):_________________________ ______________________________________________________________________________________________________________________________________________________(4) Regular Practices ( Exercise/hatha yoga (Specify) ( None/Never ( Occasional ( Several times per week ( Daily ( Several times per month( Team Sports/Recreation (Specify) ( None/Never ( Occasional ( Several times per week ( Daily ( Several times per month( Travel (Include commute if applicable) ( None/Never ( Occasional ( Several times per week ( Daily ( Several times per month( Spiritual practices (Specify) ( None/Never ( Occasional ( Several times per week ( Daily ( Several times per month( Meditation/Prayer/Pranayama (Specify) ( None/Never ( Occasional ( Several times per week ( Daily ( Several times per month( Other (Include creative activities) ( None/Never ( Occasional ( Several times per week ( Daily ( Several times per month(5) Relationship a. Please indicate how nourished you feel in your relationship: 1 2 3 4 5 6 7 8 9 10 (1 being the least nourished, 10 being the most nourished) b. How often do you engage in sexual activity (include sex with partner and masturbation): ( Daily ( Several times per week ( Several times per month ( Occasionally ( Not at all c. Is your current sexual activity satisfactory? ( Yes ( No (6) Food Choices What types of foods do you eat on a regular basis? Breakfast:Lunch:Dinner:Snacks:(7) daily LIQUID INTAKE (Indicate number of 8 ounce cups per day) ( Plain water _______________ ( Caffeinated Coffee/Tea ________( Herbal Tea or Juice__________( Cow or Goat Milk __________( Decaffeinated Coffee/Tea ______( Soda or soda pop ___________( Grain/nut/soy milk __________(8) Habitual eATING PATTERNS Describe any current or past eating patterns or any other food related issues. (9) DAILY SCHEDULE (include approximate times) What are your habitual activities from the time you wake up until you go to sleep? Include mealtimes, sleeping, exercise, work, and any activities that occur on a regular basis. TimeHabitual ActivitiesIntern NotesMorningAwaken Mealtime ActivitiesDay Mealtime ActivitiesNightMealtime Activities Bed-time(10) ALLERGIES OR SENSITIVITIES: Do you have allergic reactions to any substances (including food, pollen, medicines?) If yes, please list.________________________________________________________________________  (11) AYURVEDIC HISTORY For each category please identify your tendency over time by placing an X in the box that is most appropriate for you. If you are unsure or would like to speak to your practitioner about this please check (( ) in the column to the right. Category ( Practitioner Use Only AppetiteI prefer to eat frequently but my hunger level is variable, and I often forget to eat. Practitioner use only V( P((I have a strong appetite I prefer to eat 3x/day and rarely skip meals. _______________________________ Practitioner use only V( P((I prefer to eat 2-3x/day, but I can go without eating with no discomfort. _______________________________ Practitioner use only V( P((AppetiteIf I miss a meal, I often get light-headed, anxious or cranky. Practitioner use only V( P((If I miss a meal, I often get irritable or angry. Practitioner use only V( P((If I miss a meal, it doesnt really bother me. Practitioner use only V( P((DigestionAfter eating, I often experience gas or bloating Practitioner use only V( P((After eating, I often experience heartburn or acidity. Practitioner use only V( P((After eating, I often feel heavy or sleepy. Practitioner use only V( P((EliminationI tend to have irregular bowel movements one time per day or less. _______________________________ Practitioner use only V( P((I tend to have 1 to 2 bowel movements daily, usually with regularity and ease. _______________________________ Practitioner use only V( P((I tend to have one bowel movement per day with no straining or difficulty. _______________________________ Practitioner use only V( P((EliminationMy bowel movements are often dry and hard. At times I may strain or push. _______________________________ Practitioner use only V( P((My bowel movements are usually well-formed, but sometimes they are loose and may burn. _______________________________ Practitioner use only V( P((My bowel movements are usually well-formed, slow and easy. _______________________________ Practitioner use only V( P((WeightI usually dont gain weight very easily. _______________________________ Practitioner use only V( P((When I gain weight, it is easy to lose it. _______________________________ Practitioner use only V( P((I gain weight easily and lose it slowly. _______________________________ Practitioner use only V( P((Body TemperatureMy hands and feet often feel cold, and I prefer warmer climates. _______________________________ Practitioner use only V( P((I am warm most of the time no matter what the climate is. _______________________________ Practitioner use only V( P((I adapt easily to most conditions, but tend to feel cool. _______________________________ Practitioner use only V( P((SkinMy skin tends to be dry. When very dry it tends to feel rough. _______________________________ Practitioner use only V( P((My skin flushes easily and has a reddish or yellowish shade. _______________________________ Practitioner use only V( P((My skin is thick, smooth and often feels damp or oily. _______________________________ Practitioner use only V( P((SkinWhen I have rashes, they tend to be dry and itchy. Blemishes are usually blackheads. _______________________________ Practitioner use only V( P((When I have rashes, they tend to be red and burning. Blemishes are usually acne. _______________________________ Practitioner use only V( P((When I have rashes, they tend to be wet and oozing. Blemishes are usually white pimples. _______________________________ Practitioner use only V( P(( V PRAKRUTI: P PRAKRUTI: K PRAKRUTI:V Vikruti: P VIKRUTI: K VIKRUTI:Practitioner use only: Category ( Practitioner Use Only SleepI tend to sleep lightly and awaken very easily. It can be difficult for me to go to sleep. Practitioner use only V( P((I tend to sleep soundly and awaken with ease. Practitioner use only V( P((My sleep tends to be deep and long. It can be difficult for me to awaken in the morning. Practitioner use only V( P((Mental & Emotional Patterns StressUnder stress I often become worried or overwhelmed. _______________________________ Practitioner use only V( P((Under stress I often become irritable, but usually rise to the challenge. _______________________________ Practitioner use only V( P((Under stress, I often withdraw to observe or become reclusive. _______________________________ Practitioner use only V( P((Decision MakingI am changeable and often have difficulty making decisions. _______________________________ Practitioner use only V( P((I make decisions easily, but can change my mind with new information. _______________________________ Practitioner use only V( P((I am careful but easy-going about decisions. _______________________________ Practitioner use only V( P((ProjectsI like to start projects, but at times have difficulty finishing them. _______________________________ Practitioner use only V( P((I like to start and finish projects. Completion is important to me. _______________________________ Practitioner use only V( P((I like working on a project, but prefer to let others start them. _______________________________ Practitioner use only V( P((PersonalityWhen I am balanced I feel creative, enthusiastic, and vivacious. _______________________________ Practitioner use only V( P( (When I am balanced I feel perceptive, disciplined, and logical. _______________________________ Practitioner use only V( P( (When I am balanced I feel nurturing, calm, and devotional. _______________________________ Practitioner use only V( P((For Women Only Is there a possibility you are pregnant? (Yes ( No ( Possible Are you menopausal? (Yes ( No If yes, date of last period ____________ If menopausal, please answer below according to your past menstrual patterns.I experience PMS: (often (sometimes (not at all (cramps (bloating (headache (weight gain (irritable (breast tenderness _______________________________ Practitioner use only V( P(My menstrual cycle is irregular. It comes every ___ to ___ days and lasts ___days. _______________________________ Practitioner use only V( P((My menstrual cycle is regular. It comes every ____ days, and lasts _____ days. _______________________________ Practitioner use only V( P((My menstrual flow is often light, but may vary. _______________________________ Practitioner use only V( P((My menstrual flow is medium heavy, and is usually consistent. _______________________________ Practitioner use only V( P((My menstrual flow is heavy and is very consistent. _______________________________ Practitioner use only V( P((I often have severe, cramping pain during menses. _______________________________ Practitioner use only V( P((At times, I have mild pain during menses. _______________________________ Practitioner use only V( P((I rarely have pain during menses. _______________________________ Practitioner use only V( P(( V PRAKRUTI: P PRAKRUTI: K PRAKRUTI:V VIKRUTI: P Vikruti: K Vikruti:Practitioner use only: (12) CURRENT MEDICATIONS, HERBS OR SUPPLEMENTS What medications, herbs, and supplements are you currently taking? Please include significant remedies that you have stopped taking, including birth control and hormone replacement therapies. SubstanceOver-the-counter (OTC) Prescription? (Rx)Herb/Drug/ Vitamin?Prescribed by? (Self, MD, other)For what purpose?For how long?What dosage?What have the benefits been?          Page a b c d e (13) Challenging patterns   eLIMINATIONFrequency Number of times per week, month or yearIntensity 1-10Constipation (less than 1 bm/day)Alternating constipation & diarrheaFood particles in stoolDiarrheaRectal pain or hemorrhoidsBlood in stoolMucus in stool Abdominal pain V:P:K:     PATIENT NAME: _______________________________________________________ Section One Intake- PAGE 8 Jennifer Ahn  HYPERLINK "http://www.JennyAhnWellness.com" JennyAhnWellness.com 562 338 5255 PATIENT NAME: ______________________________________________________ Section One Intake- PAGE 1 Name: Address: City, State, Zip: TelephoneHome: Cell: Work: E-mail: _______________________________ Birth date: _________________ Age: ____________________________ Marital/partner status: # of children: Ages: Occupation: Emergency contact name and number: _______________________________________________________________ How did you hear about Ayurveda? Please explain your main concerns, and what you hope to accomplish in working with an Ayurveda Health Practitioner: ______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ What You Can expect from your ayurvedic health care Ayurveda is a natural healing system that has been successfully practiced for thousands of years. Originating in ancient India, this medical tradition states that each persons path toward optimal health is unique--because each person is unique. The healing programs we offer at the AwakeningYogi are based on effective, time-honored principles that focus on understanding your particular body-mind constitution and the unique nature of your imbalance. Each program is individualized and formulated by your practitioner to help fulfill your needs for optimal health and healing. Your program may include lifestyle adjustments, dietary changes, herbs, color therapy, sound therapy, aroma therapy, massage therapy, and other natural therapeutics. In order to successfully implement these Ayurvedic principles into your life, frequent regular follow-up visits with your practitioner are recommended over a six- to twelve-month period. 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. Patient (or Guardian) Signature: Date: All Patients who participate in Ayurvedic health care through this program should be advised of the following information: Your Ayurvedic Health Practitioner has completed all of the academic requirements of the California College of Ayurveda. Your practitioner will work with you on the promotion of optimal health and well-being. Please note that your practitioner will not be working with you on specific symptoms or diseases. By changing your lifestyle and living more harmoniously, you will create within yourself the optimum environment for healing to take place and a greater sense of well-being. Remember that healing is a process.and that it requires time and patience. It is recommended that you continue with your practitioner for at least 6 months for optimal benefits and results. If you have specific symptoms that you are concerned about, we recommend that your condition be evaluated by a licensed healthcare professional. If you are under medical care or the care of another healthcare provider, your work with your Ayurvedic Health Practitioner will compliment the work being done by your other providers. If you are not under the care of another healthcare provider, the work that you do with your Ayurvedic Health Practitioner will help prevent disease and support your overall well-being. The California College of Ayurveda is not a Medical College and its Staff, Interns, and Residents are not trained in Western medical diagnosis and may not alter your prescription medications. While your Ayurvedic practitioner may take your blood pressure and vital signs, and perform some examination techniques similar to a routine medical examination, your intern is evaluating their findings from an Ayurvedic perspective only and not from a Western medical perspective. This examination does not take the place of a medical evaluation. If, as a result of their examination, any findings suggestive of a possible medical imbalance is found, your practitioner will refer you to a Medical Doctor for further evaluation. By signing below, you give your permission to Jennifer Ahn to use the information in your chart for research purposes (Note: No patients names, addresses, phone numbers or email addresses are included in research records). I have read and understand the above information and give my permission to begin a program health promotion with Jennifer Ahn. Patient (or Guardian) Signature: ________________________________________Date: _______________________ Please indicate any physical and emotional patterns that you find challenging by assigning a Frequency (a number of times per week, month or year) and Intensity (a number from 1 to 10): Intensity 1 to 3 = mild discomfort 4 to 6 = moderate discomfort 7 to 10 = severe discomfort eMOTIONSFrequency Number of times per week, month or yearIntensity 1-10WorryAnxietyOverwhelmSelf-destructivenessAngerResentmentCritical/BlamingIntenseLethargicMelancholyDepressionStubbornness Please describe your energy level: Vikruti Practitioner Notes: DIGESTIONFrequency Number of times per week, month or yearIntensity 1-10Excessive gasExcessive belchingAcid refluxBurning indigestionNausea or vomitingSleepy after eatingHeaviness after eatingBloated after eating ()*K õ~wpwh_U_QLC< h;CJ jqhCJ h6hh59>*CJh59CJjh3?U ho6] h3?6] hfx6]h3?9CJ aJ 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