JulieAnnWardwellClinicalAyurvedaSpecialistCell(508)2873161,Fax(508)7446654

CONFIDENTIAL CLIENT HISTORY

Name: __________________________________________________________________
Address: ________________________________________________________________
_______________________________________________________________________
Telephone Home: ______________________ Cell: ____________________________
Email: __________________________________________________________________
Birth date: ______________ Age: _________
Partner status: ____________________# of children: _____ Ages: __________________
Occupation: _____________________________________________________________
Referred by: _____________________________________________________________
OBJECTIVES
1. Please check the items that reflect your main objectives:
I want a holistic approach to my health and managing illness and dis-ease.
I want to improve my general health and wellness and reduce my vulnerability to
illness and disease
I want to improve my lifestyle and dietary practices to improve my health
I want to change my habits and behavioral patterns to improve my relationships with
others
I want to manage stress, tension and worry to attain a more stable emotional nature
2. What do you want to achieve or change in terms of your health and wellness?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
3. How would your life be different if you were to achieve these objectives to your
satisfaction?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
REVIEW OF CURRENT CONCERNS
4. What are your major health concerns?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
5. When did this begin?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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JulieAnnWardwellClinicalAyurvedaSpecialistCell(508)2873161,Fax(508)7446654

6. Has anything recently changed or become worse?

________________________________________________________________________
________________________________________________________________________
7. Have you had a diagnosis? If so, what was it, how was it arrived at, and by whom?
________________________________________________________________________
________________________________________________________________________
8. Are you currently receiving care from any other health professional?
(Name)_________________________________________________________________
_______________________________________________________________________
9. Have you been under the care of a licensed health care practitioner in the past year?
Yes No - If so, for what reasons:
_______________________________________________________________________
_______________________________________________________________________
10. Do you see a chiropractor, massage therapist or acupuncturist? Yes No
Name: __________________________________________________________________
11. Other Significant Symptoms:
________________________________________________________________________
________________________________________________________________________
12. Other Diagnosed conditions and date of diagnoses.
________________________________________________________________________
________________________________________________________________________
PAST HEALTH CONDITIONS
13. Serious illnesses/dates:
_______________________________________________________________________
________________________________________________________________________
14. Hospitalizations/dates:
________________________________________________________________________
________________________________________________________________________
15. Operations/dates:
________________________________________________________________________
________________________________________________________________________

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JulieAnnWardwellClinicalAyurvedaSpecialistCell(508)2873161,Fax(508)7446654

Height __________ Current weight__________ Desired weight _________

Weight 1 month ago__________ Weight 1 year ago__________

Health Concerns or challenging symptoms

Please check off any symptoms that you are currently experiencing. Even if the
symptoms are mild. This information will explain how your mind and body reacts.
Frequency
1 = Daily
2 = Several times per week
3 = Several times monthly

Intensity
1 to 3 = Mild discomfort
4 to 6 = Moderate discomfort
7 to 10 = severe discomfort

Digestion
F

Gas Non odor

Belching
Bloating
Food cravings

Gas with odor

Heartburn
Acid Reflux
Sores on tongue or
inside mouth
Ulcers
Excessive appetite
Loss of taste

Food allergies
Abdominal pain
Variable appetite

Nausea after eating

Vomiting
Difficulty swallowing
Heaviness after
eating
Sleepy after eating
No feeling of hunger

Elimination
F
Constipation
Dry stools
Rectal pain
Irregular
elimination
Food particles in
stool
Weight loss
more than 5lbs.

F
Diarrhea
Loose stools
Blood in stool
Regular elimination

Black stool

Heavy stool
Mucous in stool
Slow to pass stool
Pass stool only
after eating a meal
Light stool

Weight gain
abdominal

Weight gain
hips and thighs

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JulieAnnWardwellClinicalAyurvedaSpecialistCell(508)2873161,Fax(508)7446654

Neuropsychology
F

Worry
Anxiety
Overwhelm
Feeling spacey
Indecisive
Poor memory
High stress
levels
Dizziness

Irritable
Anger
Rage
Resentment
Jealousy
Envy
Critical of others

Lethargy
Sadness
Depression
Greediness
Over attachment
Grief
Procrastination

Critical of self

Seizures
Headaches

Intense thinking
Sharp responses

Difficulty
concentrating
Poor mental clarity
Changing emotions

Skin, Hair, and Nails

F

Dry skin
Itching
Rashes
Hives
Bruise easily
Change in
texture
Nails that chip
or crack

Oily skin
Hair loss
Eczema
Psoriasis
Dandruff
Poor healing sores

Acne red pimples

Acne white pimples
Acne black pimples
Moles
Brown spots
Excessive sweating

Nails with white

spots

Nail fungus

Ears and eyes

F

Poor Hearing
Ear Pain
Ear infections
Ringing in ears
Dizziness

Dry eyes
Red eyes
Watery eyes
Spots or tracers
Light sensitive

Eye pain
Dark circles
Near or Farsightness
Astigmatism
Glaucoma

Head, Nose, and Throat

F
Jaw pops or
locks
Grinding teeth

Tooth decay

Mucous in throat or
post nasal drip
Chronic clearing
of throat
Frequent colds

Bleeding gums
Bad breath
Tonsils removed
Loss of smell

Canker sores
Nose bleeds
Deviated septum
Nose bleeds

I
Facial pain
Swollen glands
Chronic Sinus
congestion
Cold sores
Allergic rhinitis
Sore throat
Burning sinuses

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JulieAnnWardwellClinicalAyurvedaSpecialistCell(508)2873161,Fax(508)7446654

Cardiovascular
F

Cold hands
Cold feet

Low blood pressure

High blood
pressure
Angina

Anemia
Intolerance to
heat or cold
Fainting
Chest pain

Irregular heart beat

High cholesterol
Arteriosclerosis or
Hardened arteries
Arthrosclerosis or
blocked arteries
Heart disease

Heart murmur
Heart attack

Heart surgery
Stroke

Respiratory
F

Dry cough
Brown or gray
phlegm
Pain on
breathing
Shortness of
breath without
exertion

Coughing blood
Yellow or green
phlegm
Bronchitis

Moist cough
White phlegm
Asthma

Difficulty breathing
while lying down

Asthma while
exercising

Urinary
F

Painful urination
Urinary urgency
Frequent
urination
Inability to hold
urine
Dark yellow or
brown urine

Blood in urine
Kidney infections
Bladder infections

Kidney stones
Decreased flow
Increased flow

Slow to start

Awaken more than

once during the night
Clear or mucousy
Sweet smell

Bright yellow
strong odor

Musculoskeletal
F
Neck Pain
Back Pain
Joint pain
Foot pain

F
Sore muscles
Weak muscles
Stiff muscles
Cramping muscles

I
Hot or swollen joints
Arthritis
Bone loss
Reduced range of
motion

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JulieAnnWardwellClinicalAyurvedaSpecialistCell(508)2873161,Fax(508)7446654

Female Reproductive
F
Irregular cycles
Heavy bleeding
Prolonged
bleeding
Spotting mid
cycle
Unusual
bleeding or clots
Fibroids

F
Menstrual cramps
Menstrual bloating
Painful breasts

Water retention

Painful intercourse
Vaginal dryness
Hot flashes
Night sweats
Infertility

Irritability

Yeast infections

Ovarian Cysts

Breast lumps or cysts

Female Reproductive
Is there a possibility that you are pregnant?_____________________________________
Age at first menses? _______________________________________________________
Date of last PAP smear? _______________________Breast exam?__________________
Are you on birth control?____________________Type?__________________________
Do you keep track of your menses on a calendar? ________________________________
# of Pregnancies?___________Miscarriages?___________Premature births?__________
Onset of Menopause?__________________Are you taking HRT?___________________
Describe your menstrual pattern. If menopausal, describe pattern when still menstruating.
Regularity: Irregular____Variable______Regular____________________
Quantity of flow: Variable_____Light_____moderate______Heavy______
Level of discomfort: Painful________Mild Pain_______Painless_________
Length of cycle: # of days?_______
Describe any gynecological problems: ________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Sexual Activity
According to Ayurveda, a persons level of sexual activity impacts health and well-being
in the same way as other aspects of daily lifesuch as diet or sleep.
16. How often do you engage in sexual activity? Include with or without a partner.
Daily_____Several times per week_____Several times per month_____Not at all______
17. Is your current sexual activity satisfactory? __________________________________

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JulieAnnWardwellClinicalAyurvedaSpecialistCell(508)2873161,Fax(508)7446654

Lifestyle Activities
18. Do you exercise regularly? ______________________________________________
Length of time: __________________ Times per week: __________________________
Type(s) of exercise: _______________________________________________________
19. How much of the following do you drink?: (Indicate number of 8 ounce cups per day)
Plain water: _______ Caffeinated Coffee: _______ Decaf coffee: _______
Herbal Tea: _______ Caffeinated tea: _______ Decaf tea: _______
Juice: _______ Soda: _______ Soy milk: _______
Cow milk: _______ Grain or nut milk: _______ Other: _______
20. Do you drink alcohol? _____________________________________________
If yes, how often daily several times weekly several times monthly seldom I
usually choose: beer red wine white wine sweet or hard liquor
21. Do you currently smoke? ______________________________________________
How many cigarettes per day? _______How long have you smoked?_______________
Have you ever smoked? Yes No If yes, when did you quit? ____________________
22. Any current or past use of addictive substances and recreational drugs? __________
Substance: _________________Amount: ______________ If quit, when? ___________
23. Do you experience allergic reactions to any substances (food, environmental, etc.)?
Please explain: ___________________________________________________________
_______________________________________________________________________
24. Please describe your work life (1 = least, 5 = most):
Level of stress: (please circle): 1 2 3 4 5 Level of work satisfaction: 1 2 3 4 5
25. Please describe your primary intimate relationship:
Level of stress: (please circle): 1 2 3 4 5 Level of satisfaction: 1 2 3 4 5
26. Are you currently experiencing stress in any other close relationship?_____________
Level of stress: (please circle): 1 2 3 4 5 Level of satisfaction: 1 2 3 4 5
27. What country/countries are your ancestors From?_____________________________
________________________________________________________________________
28. Do you have any specific spiritual practices now? Please describe _______________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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JulieAnnWardwellClinicalAyurvedaSpecialistCell(508)2873161,Fax(508)7446654

________________________________________________________________________
29. How many hours of sleep do you get in 24 hours?_____________________________
30. Do you feel refreshed upon awakening? Always Most days Half the time
Rarely Never
31. At end of day: Do you have enough energy to do what you want to do?
Always Most days Half the time Rarely Never
32. Describe your sleep patterns. Do you go to bed at a regular time? Do you sleep
through the night? How many times do you wake up to go the bathroom? What time do
you wake up in the morning. Do you have insomnia? How Often?
________________________________________________________________________
________________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Dietary Patterns

Meal

Time
of day

List Typical foods and beverages

Breakfast
Snacks
Lunch
Snacks
Dinner
Late
Night

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JulieAnnWardwellClinicalAyurvedaSpecialistCell(508)2873161,Fax(508)7446654

33. Do you eat for emotional reasons? ________________________________________

Food choices: ____________________________________________________________
34. Do you graze, for example have a jar of nuts at your desk at work and eat them
throughout the day? _________Food choices for grazing:__________________________
________________________________________________________________________
35. Do you have any routines around eating (say grace, sit in silence before your meal,
etc.)? Please explain: ______________________________________________________
36. Any current or past eating patterns or any other food related issues?______________
Describe: _______________________________________________________________

Time of day Describe Daily Activities and Environment

Awaken
Activities
Breakfast
Activities
Lunch
Activities
Dinner
Activities
Bedtime
List any other information you think may be important.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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JulieAnnWardwellClinicalAyurvedaSpecialistCell(508)2873161,Fax(508)7446654

________________________________________________________________________
________________________________________________________________________
Current medications, herbs, and supplements
What medications, herbs, or supplements are you currently taking? Please include
significant remedies that you have recently stopped taking. Please also include birth
control and hormone replacement therapy.
Substance

For each
substance,
indicate if
over-the
counter
OTC or
prescription

Prescribed by
whom?
MD, Self
Chiropractor

Taken
for
what
purpose?

Taken
for
how long?

What is
your
current
dosage?

What have
been the
benefits?

Family Medical History

Please complete this section only for family members with particular health problems.
If the family member is deceased, please list age at death & cause of death.
Relation
Father

Age

Health problem

Mother
Sister
Brother
Children

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JulieAnnWardwellClinicalAyurvedaSpecialistCell(508)2873161,Fax(508)7446654

Informed Consent and Disclaimer

A Clinical Ayurveda Specialist is not trained in Western diagnosis or
treatment and will not make suggestions about altering your medical care or
medications. In the United States , Ayurveda is a non-licensed profession. Its
practice was formally legalized under the passage of Senate Bill 577 in
January 2003.
If you are suffering from a disease or symptom that has not been evaluated
by a Medical Doctor or another licensed health care professional, we
recommend that you receive a proper evaluation. As part of the Initial
consultation we may take your blood pressure and vital signs, and perform
some examination techniques similar to a routine medical examination, we
are evaluating our 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 during
the examination, any findings are suggestive of a possible medical
imbalance we will refer you to a Medical Doctor for further evaluation.
By signing below, you give your permission to Chalice Well Ayurveda to
begin a program of Ayurvedic health care with a Clinical Ayurveda
Specialist.
Patient's Signature: ___________________________________________
Todays Date: ________________________________________________

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JulieAnnWardwellClinicalAyurvedaSpecialistCell(508)2873161,Fax(508)7446654

WHAT TO 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 are time-honored principles that
focus on understanding your particular body-mind constitution and the
unique nature of your imbalance.
Each individualized treatment program is formulated by a Clinical Ayurveda
Specialist who has completed 1800 hours of training, plus an additional 600
hours of Advanced Ayurveda Herbalism, and Yoga Sadhana and Pancha
Karma training from the California College of Ayurveda. 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 are recommended over a six- to twelvemonth 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.
Patients Signature: __________________________________________
Todays Date: ______________________________________________

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