Ayurvedic Dosha Quiz

Student Clinic Health Information & History Intake

Please call or arrive on time for your appointment. Due to scheduling restrictions we cannot delay your appointment for missing application forms. We apologize for any delays in the clinical schedule (generally less than fifteen minutes).

My student consultant's name is:

I am aware that my student consultant is enrolled in a 500-hour Ayurveda studies program and has not graduated from this program (expected to graduate by ).

My student consultant will provide a 90-120 minute educational Ayurvedic consultation in order to:

Determine my mind-body constitution
Identify and assess any imbalances that may exist
Provide information and guidance relevant to helping me nourish, stimulate or balance vital energy
Develop a plan with me for lifestyle changes that may improve my general health and wellness

Agreements & Consent

I agree to study the information provided, participate in the development of my health plan, and implement it according to my ability. I agree to notify my primary care provider of my intention to begin a new health & wellness plan. I agree to discontinue the plan if discomfort occurs and notify my consultant and physician. I agree that in the case of disputes, I will submit such claim to the American Arbitration Association. I agree that Twin Beans Farm is not responsible for any information provided by the student, which may contain errors, and that any injury is entirely my responsibility. I acknowledge my health information may be shared with Twin Beans Farm staff and students for educational purposes (excluding personally identifiable info).

Client Signature (Type Name)

Date

Personal Details

Client Name

Daytime Phone

Address

City, ST, Zip

Email

Cell

Age

DOB

Marital Status

Occupation

Referred By

Family Physician

Objectives

Select the item below that reflects your main objective (one only). Please note that Ayurvedic Consultations do not include medical diagnosis and treatments. If you are concerned about a medical condition, you should see a medical doctor.

I want an alternative approach to allopathic medicine for managing illness and disease I want to improve my general health and wellness and reduce my vulnerability to illness and disease I want to improve my lifestyle and dietary practices to improve my health I want to change my habits and behavioral patterns to improve my relationships with others I want to manage stress, tension and worry to attain a more stable emotional nature

What do you want to achieve in terms of your health and wellness? Please also tell us your current concerns.

Medical History

Check appropriate boxes if you or your family members have a history of the following:

Any Other Diseases Or Problems? (Illnesses, injuries, addictions, weight changes, surgeries, etc.)

Current Health & Vitals

Are you currently under a physician’s care?

Last Physical Exam Date

Height

Weight

What prescription drugs are you taking (including birth control)?

What non-prescriptions drugs, supplements, or recreational drugs are you taking (including alcohol, tobacco, caffeine)?

Diet & Elimination

Please write down all food you have eaten and drank for the last three days, with timing.

When and how often do you eliminate? What does your poop look like (color, shape, quantity, odor)?

Required Photos

Please email the following photos before your first appointment (at least 48 hours prior), and at least once a year afterwards. You can send separate photos, or save all together in a google drive link.

Full length photo from the front
Full length profile from the side
Close up of face
Close up of both hands, palms downward
Entire top of tongue, including back (when you first wake up in the morning, before scraping)
Close up of eyes looking to the right & left
Full length childhood photo before the age of 5

Student Consultant Client Relationship

If your student consultant sees you in public, he/she usually won't acknowledge you until you acknowledge him/her first. This is to maintain your confidentiality. To keep your relationship professional, please refrain from asking personal questions about your student consultant.

Twin Beans Farm is an educational institution specializing in Ayurveda, nutrition, and digestive health. Consultations are limited to nutrition and digestive-health support and do not replace medical diagnosis, treatment, or care provided by a licensed physician. It is not an agreement for ongoing care.