Health Test – Vrinda Ayurveda

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Name

First

Last

Age

Gender

Height (in cm)

Weight (in kg)

Phone

Do you have any pre-existing medical conditions? (e.g., Diabetes, Hypertension, Heart Disease)

Are you currently taking any medications? If yes, please list them.

Have you had any surgeries in the past? If yes, please provide details.

Do you have any allergies? If yes, please specify.

How often do you exercise?* (Daily, Weekly, Rarely, Never)

Do you smoke or use tobacco products?

Do you consume alcohol?

Describe your typical daily diet.

How many hours of sleep do you get on average?

Do you experience any stress or anxiety on a regular basis?

Have you been diagnosed with any mental health conditions?

Do you feel that your mental health affects your physical health?

What are the primary health concerns you are experiencing?

How long have you been experiencing these symptoms?

Have you received any treatment for these symptoms? If yes, please describe.

Are your symptoms improving, worsening, or staying the same?

Do you have a family history of any medical conditions? (e.g., Heart Disease, Diabetes, Cancer)

Has anyone in your family had similar symptoms?

What are your primary health goals? (e.g., Weight Loss, Improved Fitness, Stress Management)

What do you expect from this personalized treatment?

Do you consent to share your medical history and personal information for the purpose of creating a personalized treatment plan?

Do you agree to the terms and conditions of the treatment?

Start Your Health Test