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Ayurvedic Intake Form
Please note that this form is HIPPA compliant to ensure privacy and confidentiality.
Client Information
First Name
(Required)
First
Last Name
(Required)
Last
Email
(Required)
Phone
(Required)
Communication Preference
(Required)
Email
Phone Call
SMS Text
Mailing Address
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Person filling out the form (if not the client)
First
Last
Relationship to client
Spouse/Partner
Parent
Sibling
Friend
Other
Emergency Contact Information
Emergency Contact Name
(Required)
First
Last
Emergency Contact Phone
(Required)
Relation to you
(Required)
Spouse/Partner
Parent
Sibling
Friend
Other
Background/Demographic Information
Date of Birth
(Required)
Month
1
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Day
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1934
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1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Age
(Required)
Gender
(Required)
Female
Male
Non-binary
Prefer not to say
Other
Height
(Required)
Occupation
(Required)
Marital Status
(Required)
Single
Domestic Partnership
Married
Divorced
Widowed
Separated
Other
Location of Birth
(Required)
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Ethnicity
(Required)
Caucasian/White
African American/Black
Hispanic/Latino
Asian
American Indian/Alaskan Native
Pacific Islander/Hawaii Native
Mixed Race
Other
Which best describes your living situation?
(Required)
Live alone
Live with partner/spouse
Live with family/relatives
Live with roommate(s)
Other
How did you hear about Kreem Shakti?
(Required)
Online Search
Word of Mouth
Social Media
Event
Advertisement
Other
Personal Medical History
Please select all medical conditions you have experienced.
AIDS
Alcoholism
Anemia
Anorexia
Appendicitis
Arthritis
Asthma
Bleeding disorder
Breast lump
Bronchitis
Bulimia
Cancer
Chemical dependency
Chicken pox
Crohn's
Diabetes Type I
Diabetes Type II
Emphysema
Epilepsy
Glaucoma
Goiter
Gonorrhea
Gout
Heart attack
Heart disease
Heart problems
Hepatitis A
Hepatitis B
Hepatitis C
Hernia
Herpes
High blood pressure/Hypertension
High cholesterol
Kidney disease
Liver disease
Measles
Miscarriage
Multiple sclerosis
Psychiatric care
Vaginal disease
Allergies
Alzheimer's
Arthritis
Asthma
Blindness
Blood clots
Breast disease
Chronic pain
COPD/Emphysema
Dementia
Endometriosis
Epilepsy
Fibroids
Hearing impairment
Hemorrhoids
HSV (Herpes)
Incontinence
Intersex condition
Irritable Bowel Syndrome
Migraine headaches
Mononucleosis
Mumps
Osteoporosis
Pacemaker
Pancreatitis
Pituitary Adenoma
Pnemonia
Polio
Polycystic Ovarian Syndrome (PCOS)
Prostate problems
Rheumatic fever
Scarlet fever
Sleep apnea
Stomach ulcers
Stroke
Suicide attempt
Thyroid problems
Tonsilitis
Traumatic brain injury
Tuberculosis
Typhoid fever
Vaginal discharge
Vaginal disease
Other condition not listed
None of these conditions
Additional conditions and information:
Please include specific information for any conditions you selected in the previous question.
Medical Condition
Do you feel this condition is managed well?
How long have you had this diagnosis
Who is your treating physician?
What type of treatment(s) have you received?
Add
Remove
Mental Health History
Please select all mental health conditions you have.
ADD/ADHD
Alcoholism (sober or currently using)
Anxiety
Autism Spectrum Disorder
Bipolar I
Bipolar II
Depression
Eating Disorder
Obsessive Compulsive Disorder
PTSD
Schizoaffective Disorder
Substance Use Disorder (sober or currently using)
Other mental health conditions not listed
None the above
Additional conditions and information:
Please include specific information for any conditions you selected in the previous question.
Medical Condition
Do you feel this condition is managed well?
How long have you had this diagnosis
Who is your treating physician?
Add
Remove
Reproductive History
Please indicate whether reproductive medical history is applicable to you.
(Required)
Yes
No
Please select all that you have experienced.
Pregnancy
Given Birth
Had a Miscarriage
Had an Abortion
None of the above
Age of first Menses
Average duration of Menses Cycle
Date of last Menses
Month
1
2
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4
5
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11
12
Day
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30
31
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
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2003
2002
2001
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1999
1998
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1995
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1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
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1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Date of last PAP
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
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11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Are you currently using a form of birth control?
Yes
No
Surgical History
Have you undergone any surgeries or medical procedures?
(Required)
Yes
No
Please list any surgeries or medical procedures you have undergone.
Surgery/Procedure Performed
Date of Surgery/Procedure:
State/Location of Surgery/Procedure
Add
Remove
Hospitalizations
Other than for surgery or childbirth, have you ever been hospitalized overnight for a medical or mental health issue?
(Required)
Yes
No
Please add additional information about your hospitalizations
Purpose of hospitalization
Date of hospitalization
Any procedures/treatments provided
Add
Remove
Allergies
Please list all allergies you have.
Include all allergies to medications, foods, animals, and insects, as well as seasonal.
Allergy
Allergic Reaction
Add
Remove
Medications
Please include any prescription, over the counter, vitamins, supplements, and herbs that you take (regularly and as needed)
Please list what medications you currently take.
Medication Name
Daily Dosage
What is it for?
How long have you been taking this?
Add
Remove
Do you often have trouble remembering to take medicines?
Yes
No
Medical History of Blood Relatives
Please select if any of your blood relatives have had the following.
(Required)
Alcoholism
Alzheimer’s Disease
Blood Clots
Breast Cancer
Cervical Cancer
Colon Cancer
Diabetes
Drug User
High Cholesterol
High Blood Pressure
Heart Attack
Heart Surgery
Mental health issues
Osteoporosis
Ovarian Cancer
Parkinson’s Disease
Prostate Cancer
Sickle Cell Anemia
Stroke
Thalassemia
Thyroid Condition
Not Listed
None the above
Add all of the checked conditions in the field below. You can add additional lines by clicking the + button on the right side.
Hidden
Blood Relative Medical History Count
Condition/Relation
Please be as specfic as posible, including which side of your family the relative is.
Medical Condition
How is this person related to you?
Add
Remove
Lifestyle Information
How many days per week do you engage in physical activities that result in sweating?
(Required)
Please enter a number from
0
to
7
.
Please list all physical activities you engage in.
(Required)
Physical Activity
Average Time Duration
Add
Remove
How many days per week do you watch TV or surf the internet?
(Required)
Please enter a number from
0
to
7
.
Do you watch TV, read, or surf the internet while eating meals?
(Required)
Always
Often
Sometimes
Rarely
Never
Please select any activities you have difficulties with.
(Required)
Speech/Communication
Memory
Dressing
Bathing
Household duties
None of the above
How many hours of sleep do you get on average?
(Required)
How do you connect with yourself?
Activity
How long do you spend doing this?
How many times per week do you do this?
Add
Remove
In the past week, what has been your stress level?
(Required)
Please select the number that best corresponds to your stress level, with 1 indicating no stress and 10 indicating the worst possible stress level.
Please enter a number from
1
to
10
.
In the past week, what has been your energy level?
(Required)
Please select the number that best corresponds to your stress level, with 1 indicating no energy and 10 indicating you feel fully energized.
Please enter a number from
1
to
10
.
Are you often hungry at meal times?
(Required)
Never
Rarely
Sometimes
Often
Always
Are your day to day meal times consistent?
(Required)
Never
Rarely
Sometimes
Often
Always
Are you able to easily skip meals?
(Required)
Never
Rarely
Sometimes
Often
Always
How often do you experience hunger throughout the day?
(Required)
Never
Rarely
Sometimes
Often
Always
If your hunger is not gratified, do you feel uncomfortable or irritable?
(Required)
Never
Rarely
Sometimes
Often
Always
How often do you feel full earlier than expected at the start of a meal?
(Required)
Never
Rarely
Sometimes
Often
Always
How consistently is your food digested from day to day?
(Required)
Never
Rarely
Sometimes
Often
Always
Please list any habits you partake in, and your level of use.
Alcohol, coffee, tea, tobacco, and marijuana are common habits.
Habit
Level of Use (light, moderate, heavy)
Add
Remove
Personal Preferences
You may have more than 1 answer to the following questions. Please select the 1 that you feel is more dominant.
What type of weather do you prefer?
(Required)
Warm
Cool
Which of these weather conditions is difficult for you to tolerate?
(Required)
Hot
Cold
Humid
How often do you feel thirsty?
(Required)
Often
Moderate
Rarely
How often do you sweat?
(Required)
Often
Not that much, unless from physical activity
Rarely
Which of these explains your decision making?
(Required)
I change my mind often
I can easily make a decision and stick to it
I prefer others to make decisions
What taste(s) do you prefer most?
(Required)
Select all that apply.
Sweet
Salty
Sour
Bitter
Astringent
Purpose of Consultation
What are you hoping to achieve with this consultation and work with Kreem Shakti?
(Required)
Concern
(Required)
Description of the main concern you would like to address
How severe is this concern?
Very severe, restricts my daily routine
Severe
Somewhat severe
Not severe, but some discomfort
Additional concerns you would like to address
(Required)
Please select the number that best corresponds to your experience.
1 indicates the concern is not severe, but causes some discomfort.
5 indicates very severe, and restricts your daily routine.
Concern
Severity (1-5)
Add
Remove
Review of Symptoms
Please check all symptoms you are experiencing or have experienced in the last 3 months.
General Symptoms
(Required)
Apetite decreased
Apetite increased
Chills/Rigors
Cravings
Fatigue
Fevers
Increased/Easily induced sweating
Increased Thirst- craving cold beverages
Increased Thirst- craving hot beverages
Localized Weakness
More prone to bruising/bleeding
Night Sweats
Particular Tastes/Smells
Poor Sleep
Poor Balance
Sudden drop in energy
Tremors
Weight Gain
Weight Loss
Other symptom(s) not listed
None of these symptoms
Other symptom(s) not listed
Add
Remove
What time of day do you experience a sudden drop in energy?
(Required)
Please select the time(s) you most commonly experience this.
When waking up
Morning
Noon
Afternoon
Evening
When falling asleep
Skin and Hair Symptoms
(Required)
Change in hair texture
Change in skin texture
Dandruff
Hives
Itching
Loss of hair
More prone to breakouts/pimples
Newly discovered moles
Rashes
Skin tags
None of these symptoms
Other symptom(s) not listed
Other Skin or Hair symptom(s) not listed
Add
Remove
Head Symptoms
(Required)
Dizziness
Facial Pain
Headaches
Migraines
Neck lumps/swelling
Other symptom(s) not listed
None of these symptoms
Other Head symptom(s) not listed
Add
Remove
Eye Symptoms
(Required)
Blurred vision
Cataracts
Color blindness
Double vision
Eye pain
Eye strain
Glasses
Night blindness
Poor vision
Spots in vision
Other symptom(s) not listed
None of these symptoms
Ear Symptoms
Ear aches
Poor hearing
Ringing in ears
Other symptom(s) not listed
None of these symptoms
Nose/Throat Symptoms
(Required)
Nose bleeds
Sinus problems
Hayfever
Teeth or gum problems
Grinding teeth
Reocurring sore throat
Mouth sores
Jaw clicks
Allergies
Other symptom(s) not listed
None of these symptoms
Other eye, ear, nose, and throat symptom(s) not listed
Add
Remove
Cardiovascular Symptoms
(Required)
Blood clots
Chest pain
Cold extremeties
Difficulty breathing
Dizziness
Fainting
Irregular heartbeat
Low blood pressure
Swelling of feet
Venous swelling
Other Cardiovascular symptom(s) not listed
None of these symptoms
Other Cardiovascular symptom(s) not listed
Add
Remove
Respiratory Symptoms
(Required)
Asthma
Cough
Coughing blood
Difficulty lying down
Shortness of breath
Wheezing
Other respiratory symptom(s) not listed
None of these symptoms
Other Respiratory symptom(s) not listed
Add
Remove
Musculoskeletal Symptoms
(Required)
Neck pain, stiffness, or swelling
Back pain, stiffness, or swelling
Shoulder pain, stiffness, or swelling
Hand and/or wrist pain, stiffness, or swelling
Hip pain, stiffness, or swelling
Knee pain, stiffness, or swelling
Foot and/or ankle pain, stiffness, or swelling
Muscle weakness
Difficulty with balance
Difficulty with walking
Other Musculoskeletal symptom(s) not listed
None of these symptoms
Other Musculoskeletal symptom(s) not listed
Add
Remove
Gastrointestinal Symptoms
(Required)
Abdominal pain and/or cramps
Bad breath
Belching
Blood in stool
Chronic laxative use
Constipation
Diarrhea
Gas
Indegestion
Nausea
Vomitting
Other Gastrointestinal symptom(s) not listed
None of these symptoms
Other Gastrointestinal symptom(s) not listed
Add
Remove
Genito-Urinary Symptoms
(Required)
Blood in urine
Decrease in flow
Ecessive sexual urges
Frequent urination
Impotency
Painful urination
Kidney stones
Lack of bladder control
Urgency to urinate
Waking up from sleep to urinate
Other Genito-Urinary symptom(s) not listed
None of these symptoms
Other Genito-Urinary symptom(s) not listed
Add
Remove
How many times per night do you wake up to urinate?
(Required)
1
2
3
4
5+
Neurological Symptoms
(Required)
Anxiety
Areas of numbness
Concussion
Depression
Dizziness
Easily susceptible to stress
Irritability/bad temper
Lack of coordination
Loss of balance
Poor memory
Seizures
Treated for emotional problems
Other Neurological symptom(s) not listed
None of these symptoms
Other Neurological symptom(s) not listed
Add
Remove
Pregnancy/Gynecology Symptoms
Breast lumps
Clots
Heavier periods
Hot flashes
Irregular periods
Lighter periods
Painful intercourse
Painful periods
Premenstrual symptoms
Vaginal discharge
Other Pregnancy/Gynecology symptom(s) not listed
None of these symptoms
Other Pregnancy/Gynecology symptom(s) not listed
Add
Remove