Confidential Client History

Please take 15-20 minutes to fill out your health history and permissions.

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Have you been under the care of a licensed professional in the last 12 months?
Is there any possibility you are pregnant?
Family history
Current symptoms
Head
Ears
Eyes
Nose
Mouth
Neck
Chest
Skin
Digestion
Urinary
Muscles and joints
Nerves
Circulation
Female system
Breasts
Male system
Sleep
My hard days outweigh the good ones
Daily routine
Any past or current chronic eating disorders or food-related issues?
General habits
Do you exercise regularly?
Have you ever smoked?
Do you smoke regularly?

Financial Policy Agreement

1. Payment is due prior to or at the first appointment unless other arrangements have been made. 

2. There is no billing to insurance companies.

3. Cancellation less than 24 hours from appointment may result in fees.

Informed consent

All clients who participate in Ayurveda through Saumya Ayurveda, please be advised of the following:

1. The goal is to create an optimal environment for healing to take place and to maximize your body’s ability to heal using the principles of Ayurveda. Saumya Ayurveda provides educational information on Ayurveda.

2. Saumya Ayurveda does not provide a medical practice and does not diagnose or treat medical conditions.

3. If you are suffering from a disease, condition, symptom, etc., that has not been evaluated by a medical doctor or other licensed health care professional, you must receive an evaluation. If you chose not to see a medical doctor, you will be asked to sign an acknowledgement that seeing a MD was recommended to you.

4. Saumya Ayurveda does not alter or advise on prescriptions, over the counter, etc.

Your Signature

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Phone

612-743-4289

Email

New Mexico Location

4436 Corrales Rd

Corrales, NM 87048

 

Minneapolis Location

201 E Hennepin Ave

Minneapolis, MN 55403

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