Professional Documents
Culture Documents
Client Information
Name: ____________________________
Address: _____________________________ Phone: ______________
Email: _____________________ Vocation/Occupation:
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Chief Mind-Body concern to address:
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Questionnaire:
Please provide detailed answers to the following questions:
1.) What is your age? ________
2.) How well do you digest food? Does it take a long time? Are there any
complaints?
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4.) Whats the consistency of your wastes (urine & fecal matter)?
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6.) Are you currently taking any herbs or medications for any reasons? If so,
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20.) Are you fulfilled with your life; your chosen career/life path?
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21.) What is the main health concern that you would like to address
through Ayurvedic methods?
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