New Client Intake Form

Please take a current picture of each of the following:

A clear picture of your face

Your hands, including your fingernails

Your tongue

Your full body (clothed!)

Please tell me a little about your daily rhythms. Check all that apply:

Do you wake up at the same time every day?

Do you have a bowel movement at the same time every day?

Do you eat your meals at the same time every day?

Do you practice Ayurvedic morning habits every day?

Do you go to bed at the same time every day?

Do you have a regular meditation, yoga and/or pranayama practice?

Please tell me a little about your digestion. Check all that apply:

Please tell me a little about your elimination. Check all that apply:

I have a bowel movement daily.

I have more than one bowel movement per day.

I do not have a bowel movement every day.

I sometimes suffer from constipation.

My bowels are on the sluggish side.

I have IBS.

Please tell me a little about your stools. Check all that apply:

My stools are well-formed.

My stools are not well-formed and sometimes runny..

My stools come out in one piece.

My stools come out in small or broken pieces.

I have bouts of diarrhea.

My stools are a color other than medium brown..

I see blood in my stool.

My stools stick to the toilet.

I see mucous in my stools.

Please tell me a little about your sleep. Check all that apply:

I sleep great at night.

I have trouble falling asleep.

I have trouble staying asleep.

I wake up multiple times to use the restroom.

If I wake in the night, I fall right back asleep.

I wake up feeling rested and energized.

I experience night sweats.

I have troubling dreams.

If I have dreams, I don't remember them.

The head:

The neck:

The eyes:

The ears:

The nose:

The mouth

The chest, heart and lungs:

The abdomen:

Skeleto-muscular system:

Nervous system:

Circulatory system:

Integumentary system:

The female body:

The male body:

Mental and emotional condition:

Katherine Galligan

KatherineGalligan

Client Intake Form

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