Ayurveda Telehealth Intake Forms


Print and fill out these 5 intake forms below. If you have the ability to fill them out electronically in PDF, please do that*. Otherwise, print them, fill them out, and scan them in (or take pictures), and send them to bardoacupuncture@gmail.com *. If you would like to submit your forms via “snail mail”, please contact us.

Informed Consent Forms will be sent to you for your signature via HelloSign.com.

*These forms will be sent over email and stored electronically in password protected accounts with 2-factor authentication. If you desire enhanced security, you can leave extra sensitive information (such as particular disease diagnoses that would be damaging were there to be a privacy breach) off the forms. We can discuss that information during your live appointment.

1: Basic Health History Intake (7 pages) Health_History_intake_form

2: Basic Ayurveda Intake Form (2 pages) prakriti-vikruti-self-intake-sept2016

3: Digestion/Toxicity/Immunity Form (2 pages) Agni_Ama_Ojas_Assessment

4: Daily Routine Intake Form (1 page) Ayurveda_Daily_Routine_Intake_Form

5: Chinese Medicine Symptoms Intake Form (2 pages) TCM symptoms intake table