Saumya Ayurveda Forms: Streamline Your Ayurvedic Journey with Saumya Ayurveda

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Confidential Client History

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

First Name

Last Name

Email Address

Address

Date of Birth

Phone

Partner status

Children and ages

Occupation

Have you been under the care of a licensed professional in the last 12 months?

No

Yes

Is there any possibility you are pregnant?

No

Yes

Family history

Cancer

High blood pressure

Stroke

Diabetes

Heart disease

Mental health issues

Current symptoms

Head

Headaches

Dizziness

Fainting

Loss of balance

Difficulty remembering

Difficulty thinking clearly

Thinning or loss of hair

Ears

Hearing loss

Ringing

Earaches or pain

Discharge

Bleeding

Eyes

Pain or soreness

Redness

Burning

Mucous

Dryness

Itching

Tic or twitching

Nose

Loss of smell

Bleeding

Pain

Discharge

Post nasal drip

Sinus congestion

Mouth

Excessive thirst

Loss of taste

Strange taste

Bad breath

Lip ulcers or lesions

Dry, cracking lips

Tongue pain or sores

Bleeding gums

Receding gums

Tooth pain

TMJ

Neck

Pain

Swollen glands

Lumps