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Intake

Begin with a gentle intake.

This important first step allows Tanya to gain a deeper understanding of your health history, digestion, sleep, lifestyle habits, and wellness concerns so your care can be individualized to your unique needs.

Client Information

Complete only what applies.

Main Concerns & Goals

Medications, Supplements & Allergies

Social & Lifestyle

Relationship statusChildrenSmokingRecreational drugsSexual history concerns to discussActively trying to conceive

Past History

Illnesses Surgeries Hospitalizations Physical trauma Mental trauma Emotional trauma Other

Family History

Asthma Arthritis Autoimmune disease Birth defects Bleeding problems Cancer Diabetes Eating disorders Epilepsy Fertility challenges Gout Hayfever / allergies Heart problems Hypertension High cholesterol Kidney problems Mental disorders Multiple Sclerosis Obesity Osteoporosis Parkinsons Stroke Substance abuse Tuberculosis Thyroid problems Other

Sleep Disturbances

Difficulty falling asleep Difficulty staying asleep Difficulty waking Not rested upon waking Excessive hours Sleepwalking Recurrent nightmares

General

Fatigue Change in appetite Change in thirst Cravings Weight gain Weight loss Poor sleep Chills or fever Night sweats Sweat easily Lack of sweating Allergies Cancer Diabetes

Skin & Hair

Dryness Thinning skin Rash Itching Eczema Psoriasis Acne Recent moles Skin tags Hives / allergic reactions Ringworm Loss of hair Thinning hair Dandruff Brittle/dry skin, hair, nails Loss of eyebrow hair Other skin/hair concerns

Eyes, Ears, Nose & Throat

Eye pain / strain Redness Swollen eyelids Eye discharge Blurry / impaired vision Floaters Cataracts Ear aches / infections Ringing in ears Vertigo or dizziness Excessive ear wax Ear itchiness Sinus infections Post nasal drip / nasal obstruction Nosebleeds Snoring / obstructed breathing Loss of smell / taste Lingering odd taste Dry mouth Sores in mouth Bleeding gums Frequent cavities Mercury fillings Jaw pain / clicks Recurrent sore throat / tonsillitis Enlarged glands Enlarged thyroid Facial pain / tics Headaches Other EENT concerns

Cardiovascular

Chest pain Palpitations High blood pressure Low blood pressure Heart attack Congestive heart failure Irregular heartbeat Pacemaker Artificial heart valve Stroke Fainting Varicose veins Deep leg pain Cold hands / feet Swelling of limbs Anemia Easy bruising Other cardiovascular concerns

Respiratory

Difficulty breathing Chest tightness Sleep apnea Shortness of breath Chronic cough Bronchitis Emphysema Asthma Wheezing Coughing blood Phlegm in throat Exposure to lung irritants Other respiratory concerns

Muscle, Bone & Joints

Neck pain Back pain Shoulder pain Arthritis Bursitis Joint pain / stiffness Joint clicking Artificial joint Muscle pain Muscle weakness Muscle loss Injury or motor vehicle accident Surgery Other concerns

Gastrointestinal

Nausea Vomiting Vomiting blood Reflux / heartburn Constant hunger Loss of hunger Ulcer Bloating Distended abdomen Excessive gas / burping Gagging Frequent stomachaches Gall stones Liver disease Jaundice Intestinal parasites Constipation Diarrhea Chronic laxative use Rectal burning / pain Hemorrhoids Blood in stool Other GI concerns

Neurological

Anxiety Depression Irritability Emotional problems Loss of balance Poor memory / concentration Dizziness Seizures / epilepsy Concussion Lack of coordination Extremity numbness / tingling Paralysis Other neurological concerns

Immunity

Repeated infections Difficulty healing Increased allergies Strep throat past/current Mononucleosis past/current Tuberculosis past/current Hepatitis past/current HIV/AIDS exposure Vaccination reactions Repeated or long-term antibiotic use

Urinary

Frequent urination Urgency to urinate Incontinence Pain on urination Waking at night to urinate Urinary tract infection Blood in urine Kidney stones Pain in back, flank, or groin

Menstrual History

Cramping Irritability Anxiety Mood swings Low mood Bloating / water retention Headaches Breast tenderness Cravings Low back pain Clotting Fibrocystic breasts Heavy flow Light flow Weight gain in waist Weight gain in hips Fibroids Cysts Oily skin Foggy thinking Fatigue / drowsiness Increased facial hair Bone loss Vaginal dryness Decreased sex drive Incontinence Loss of scalp hair Fertility challenges Abnormal Pap tests Vaginal discharge Vaginal itching Nipple discharge

Men's Health

Hernia Testicular mass or pain Perform self testicular exam Low sex drive Discharge or sores Impotence / erectile dysfunction Difficulty with urination and/or frequent urination Night-time urination Prostate condition Prostate exam / bloodwork done in past

Reproductive & Sexual Health

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I understand DHARA provides educational and wellness support only, not medical diagnosis, medical treatment, psychotherapy, crisis support, or emergency care. This intake does not replace advice from a qualified medical or regulated health professional. I consent to DHARA collecting and using this information to respond to my request and support my wellness care, and I agree to the Privacy Policy, Terms of Use, and Health Disclaimer.

DHARA Ayurveda Therapies

Ayurveda wellness support, intake, resources, and appointment guidance in one calm client hub.

Alliston, Ontario

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