Personal Information

First Name *

Last Name *

Date of birth *

Address

Street Address

City

State

Country

Postal code

Email *

Emergency Contact Name & Phone: *

Phone *

Presenting Concerns

What brings you in today? *

How long have these concerns been present? *

What are your primary goals for working together? *

Mental & Emotional Well-Being

How would you describe your current emotional state? *

Have you ever been diagnosed with a mental health condition? *

Yes

No

If yes, what was your diagnosis & when were you diagnosed?

Are you currently seeing a therapist, psychiatrist, or coach? *

Yes

No

If yes, please describe your experience briefly:

Are you taking any psychiatric or mood-related medications or supplements? *

Yes

No

If yes, please list:

How do you currently cope with stress or emotional challenges? *

Do you have a history of trauma or significant life stressors that may impact your well-being today? *

Yes

No

If yes, please describe briefly your stressors:

Lifestyle Snapshot

Sleep

Average hours per night: *

Do you feel rested upon waking? *

Yes

No

Sleep issues? *

Trouble falling asleep

Waking in the night

Vivid dreams

Other:

Nutrition

How would you describe your current eating habits? *

Do you follow any specific dietary approach (e.g., vegetarian, Ayurvedic, gluten-free)? *

Do you consume caffeine, sugar, or alcohol regularly? *

Yes

No

If yes, please describe your caffeine/ sugar/ alcohol intake:

Movement & Body

Describe your current body movement/exercise routine: *

Do you have any physical conditions, injuries, or limitations? *

Yes

No

If yes, please describe them:

Mind-Body Practices

How often do you engage in them? *

Substances

Do you smoke or use nicotine? *

Do you use recreational substances? *

If yes, please descibe:

Medical & Nutritional History

Primary care physician: *

Current medical conditions: *

Surgeries or hospitalizations: *

Medications/supplements currently taken (include dose, if known): *

Have you ever had nutritional testing done? *

Have you worked with an integrative or functional medicine practitioner before? *

Ayurvedic Insight (Optional)

Time of day you feel best:

Time of day you feel most depleted:

Typical digestive pattern

Cravings:

Final Reflections

What does "well-being" mean to you at this point in your life? *

What are your top 3 priorities for improving your mental or physical health? *

Is there anything else you’d like me to know before we begin?

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