Sama Ayurveda

samabeauty@gmail.com

805-570-2692

Holistic Health Assessment Form

Date

Phone Number

Date of birth

Marital Status

Single

Married

Divorced

Separated

Widowed

What is your living situation? Living alone, with family, extended family, roommates, romantic partner live-in, etc...

Do you have any children? If so, how many and ages?

Current occupation

What would you like to change in your life at this time?.. main reason for this consultation (coaching with Maria)

In ONE word, how do you feel in your life right now?

In ONE word, what do you desire to feel right now?

What do you think is preventing you from feeling this way right now?

In ONE word, what is your desired feeling by the end of our time working together? (could be same word as how you feel right now or different ;-)

Are you familiar with Ayurveda? If so, what is your experience with it?

What behaviors/habits/patterns do feel you engage in that are not supportive to the changes you want?

If we were to work together beyond a consultation, what is your commitment level in making lifestyle/health changes? 1-10, with 10 being solid commitment.

What obstacles may be in the way to bringing you your desired outcome?

Describe any significant PAST physical or mental health issues and how you overcame them.

Describe your PRESENT health issues, concerns and approximate duration. (physical, mental, emotional)

Do you have any body pain? If so, where?

Are you still menstruating? If yes, are your cycles regular? If no, when was your last moon cycle?

Are you taking any drugs? Legal, not legal. If so, write them here.

Are you taking any herbs regularly? If so, list them here.

Do you have any addictions -- coffee, drugs, black tea, cigarettes, etc...? How long has this been a habit?

Have you experienced any traumatic experiences your life? If yes, discuss briefly.

What do you do for enjoyment, leisure, creativity?

What time do you usually wake up?

What time do you usually go to sleep?

How often do you exercise? And what forms of exercise do you do?

Do you follow a daily routine? If so, briefly list activities.

How is your energy throughout the day?

I wake up feeling refreshed and ready for day

I'm slow to wake only with caffeine

I get a second wind of energy in the evening

I feel groggy upon waking

I feel exhausted and fatigued at end of day

I feel a crash mid day

Do you have a spiritual practice?