Questionnaire

Blue Pearl Ayurveda Health Questionnaire

Please fill out the health information completely so that valuable consultation time does not have to be spent gathering health information.

Please take some time to think through your full range of health issues by completing the following questionnaire. Many times seemingly unrelated health problems are all caused by the same doshic imbalance, a fact often not recognized by Western medicine. Ayurveda can address all of your issues simultaneously and improve your overall quality of life.

Please submit your completed questionnaire to Blue Pearl Ayurveda at least 24 hours prior to your scheduled appointment so that I can review it before we speak.

Please attach a recent photograph of yourself if you have one available that can be sent by email to the address above.

Thank you!

I look forward to working together with you to improve your health.

Thomas Mitchell, D.C.

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Sex (required)  Male Female
WHERE ARE YOU EXPERIENCING PAINS?
Head
Mid Back
Lower Back
Shoulder
Arm
Forearm
Hand
Buttocks
Hip
Thigh
Leg
Foot
Currently your pain is aggravated by  Coughing Sneezing Straining at Stool Neck Movement Reaching Lifting Bending Sitting Standing Walking Other
Since your symptoms began, have you noticed a change in  Bowel Function Ability To Maintain An Erection Bladder Function
REVIEW OF SYSTEMS (GENERAL)  Normal Weight Change Fever Insomnia Chills Weakness Nausea Excess Sleep Fatigue Night Sweats Bleeding Lost of Stamina Other
EMOTIONAL  Normal Fear Phobias Mood Swings Sadness Depression Anxiety Jealousy Over Controlling Anger Irritability Judgmental/Critical Easily Frustrated Aggression Other
SKIN  Normal Nail Change Burning Pains Hair Loss Graying of Hair Itching Eczema Boils Acne Dryness Rash Psoriasis Strong Odor White/Dark Discoloration Excessive Sweating Cellulite Redness Yellowing Other
STOMACH / INTESTINES  Normal Ulcers Halitosis Abdominal Pain Constipation Decreased Appetite Sluggish Appetite Bloating Excess Thirst Vomiting Nausea Increased Appetite Diarrhea Malabsorption Excess Cholesterol Whitening of Stool Excess Triglycerides Other
RIGHT EYE  Normal Vision Trouble Pain Discharge Conjunctivitis Cataracts Other
LEFT EYE  Normal Vision Trouble Pain Discharge Conjunctivitis Cataracts Other
RIGHT EAR  Normal Hearing Trouble Ringing Pain Discharge Other
LEFT EAR  Normal Hearing Trouble Ringing Pain Discharge Other
NEUROLOGIC  Normal Memory Loss or Impairment Confusion Lack of Mental Clarity Lack of Motivation Lack of Enthusiasm Feeling Ungrounded Difficulty FocusingConcentrating Other
MENTAL  Normal Memory Loss or Impairment Confusion Lack of Mental Clarity Lack of Motivation Feeling Ungrounded Difficulty FocusingConcentrating Other
NOSE  Normal Pain Bleeding Absence of Smell Congestion Mucus Other
MOUTH / THROAT  Normal Sores Bleeding Absence of Taste Abnormal Taste Dryness Other
HEART / LUNGS  Normal Swollen Extremities Chest Pains Murmur Blue Extremities Palpitations Cough Colds Wheezing Difficulty Breathing Congestion Other
BREASTS  Normal Dimpling Lumps in Breasts Redness/Itching Discharge Other
REPRODUCTIVE / URINATION  Normal Frequent Urination Inability to Hold Urine Painful Urination Abnormal Vaginal Bleeding Irregular Menstruation Painful Menstruation Impotence Other
GLANDULAR  Normal Goiter Fibroids Heat/Cold Intolerance Tremor Hot Flashes Sugar In Urine Cysts Other
BODY / BONES / MUSCLES  Normal Stiffness Joint Pain Spasms Osteoporosis Paralysis Other
WHAT ARE YOUR HABITS?
Smoking  Never Occasionally Moderately Excessively
Alcohol  Never Occasionally Moderately Excessively
Recreational Drugs  Never Occasionally Moderately Excessively
Exercise  Never Occasionally Moderately Excessively
MEDICAL HISTORY (WOMEN)
To the best of your knowledge are you pregnant?  Yes No
Are you under the regular care of an OB-GYN?  Yes No
Have you been hospitalized in the past five years?  Yes No
Are you currently taking any medications?  Yes No
Which of the following illnesses have you had?  No Previous Conditions/Illnesses Arthritis Asthma Sinus Trouble Hay Fever Allergies Tuberculosis Diabetes Epilepsy Thyroid Trouble High Blood Pressure Low Blood Pressure Heart Trouble HIV / ARC AIDS Ulcer Cancer Polio Rheumatic Fever Serious Injury Bone Fracture Dislocated Joint Spinal Disc Disease Multiple Sclerosis Scoliosis Mental/Emotional Difficulty Prostate Trouble Kidney Trouble Sexually Transmitted Disease
FAMILY HISTORY
Cancer  Father Mother Brothers Sisters Children
Diabetes  Father Mother Brothers Sisters Children
Heart Trouble  Father Mother Brothers Sisters Children
High Blood Pressure  Father Mother Brothers Sisters Children
Stroke  Father Mother Brothers Sisters Children
Multiple Sclerosis  Father Mother Brothers Sisters Children
Headaches  Father Mother Brothers Sisters Children
Arthritis  Father Mother Brothers Sisters Children
Osteoporosis  Father Mother Brothers Sisters Children