Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
*
(###)
###
####
If you are here for meal plans, do you have any specific notes for weekly drop offs?
What's your birthdate?
MM
DD
YYYY
How did you hear about me?
*
If you selected referral on the above field, from where or who did the referral come from?
If you selected other on the above field, please explain.
What brings you here?
*
Please select all that apply
If you selected other on the above field, please explain.
Where did you grow up?
What's your relationship status?
Do you have any children?
What's your occupation?
What is your EDD? Or when did you give birth?
MM
DD
YYYY
Have you decided on your birth place + practice?
If you already gave birth, where and what practice are you with? How was your experience?
Is this your first baby?
Do you know what a Doula is?
Have you taken or are you enrolled in a Childbirth Ed course?
If you selected Yes to the above, have you taken the course yet, and what course?
How do you plan to feed your baby? Or, how are you feeding your baby, how's it going?
Do you take any supplements or medications? If so what?
Any therapies, alternative healers + helpers with which you are involved?
What role does exercise play in your life?
Please list, if any your main health concerns:
Do you have any health goals? If so what are they?
Have you had any serious illnesses/ hospitalizations and or injuries? If so what?
How is your sleep? How many hours?
How is your digestions? Do you frequently experience, constipation, gas, or loose movements?
Do you currently have any pain, stiffness or swelling?
Do you have any allergies? If so what?
Do you have any dietary preference? If so what ?
If you are here for meal service, does anyone in your household have any food allergies or preferences?
Is there any food that you DON'T like? If so what?
What is your current diet? Breakfast, Lunch, Dinner, Snacks, Beverages:
What percent of your food is home cooked?
Do you like to cook? If so what?
Do you crave sugar, coffee, nicotine, or have any major addictions?
Is there anything that you would like to change about your diet to improve your health? If so what?
Is there anything else that you would like to share?
THE THREE DOSHA'S
VATA is composed of elements, space, and air. It governs our movement, communication, and nervous
system. Vata qualities are light, clear, moving, cold, rough, brittle and small. When out of balance it can cause,
dryness, respiratory issues, poor circulation and mood disorders. Vata season is from the fall to early winter.
PITTA is composed of the elements of fire and water. It governs our energy, digestion, and metabolism. Pitta
qualities are hot, sharp, fluid, greasy, acidic, sour, pungent, light. When out of balance it can cause,
autoimmune reactions, rashes, redness, irritations, inflammation, and infection. Pitta season is from late spring
to early fall.
KAPHA is composed of the elements of water and earth. It governs our structure. It is the ‘glue’ that holds
us together. Kapha qualities are slow, steady, stable, sweet, soft, sticky, cold, heavy and dull. When out of
balance it can cause excess mucus, congestion, coughs, colds, swelling and water retention. Kapha season is
from the winter to early spring.
In the below fields please mark one or as many as two descriptions along each row, choose ones that best describe you and how you have been most of your life. You want to identify those characteristics that you were born with. This will help in identifying your constitution. When you are done hit submit, and I will follow up with you about your unique constitution and ways to work with it.
What's your physical frame?
Select up to two options that best describes the way you've been most of your life.
What's your weight?
Select up to two options that best describes the way you've been most of your life.
How much hair do you have?
Select up to two options that best describes the way you've been most of your life.
What's your hair texture like?
Select up to two options that best describes the way you've been most of your life.
What's your hair color?
Select up to two options that best describes the way you've been most of your life.
What's your skin like?
Select up to two options that best describes the way you've been most of your life.
What's your complexion like?
Select up to two options that best describes the way you've been most of your life.
What are your teeth like?
Select up to two options that best describes the way you've been most of your life.
What is your nose like?
Select up to two options that best describes the way you've been most of your life.
What are your eyes like?
Select up to two options that best describes the way you've been most of your life.
What are your nails like?
Select up to two options that best describes the way you've been most of your life.
What are your joints like?
Select up to two options that best describes the way you've been most of your life.
What's your digestion like?
Select up to two options that best describes the way you've been most of your life.
What's your usual elimination?
Select up to two options that best describes the way you've been most of your life.
How often do you sweat?
Select up to two options that best describes the way you've been most of your life.
What's your mental activity like?
Select up to two options that best describes the way you've been most of your life.
What's your memory like?
Select up to two options that best describes the way you've been most of your life.
What's your intellect like?
Select up to two options that best describes the way you've been most of your life.
What are your dreams like?
Select up to two options that best describes the way you've been most of your life.
How's your sleep?
Select up to two options that best describes the way you've been most of your life.
What's your speech like?
Select up to two options that best describes the way you've been most of your life.
How are your emotions + moods?
Select up to two options that best describes the way you've been most of your life.
How's your confidence?
Select up to two options that best describes the way you've been most of your life.
What are your relationships like?
Select up to two options that best describes the way you've been most of your life.
When threatened you tend to?
Select up to two options that best describes the way you've been most of your life.
What's your sex drive like?
Select up to two options that best describes the way you've been most of your life.
What's your physical activity like?
Select up to two options that best describes the way you've been most of your life.
What's your relationship to routine?
How's your appetite?
Select up to two options that best describes the way you've been most of your life.
How fast do you eat?
Select up to two options that best describes the way you've been most of your life.
What temperature do prefer your food + drinks?
Select up to two options that best describes the way you've been most of your life.
What is your ideal weather?
Select up to two options that best describes the way you've been most of your life.
How do you manage your finances?
Select up to two options that best describes the way you've been most of your life.
How charitable are you?
Select up to two options that best describes the way you've been most of your life.
Any additional comments?
*
Name
*
First Name
Last Name
