NIRVANA WELLBEING AYURVEDIC CONSULTATION FORM

Thank you for adding an Ayurvedic consultation to your stay at Nirvana Wellbeing Retreat.

Please fill in the pre consultation questionnaire below before attending your retreat. As always, if you have any questions or concerns, please feel free to contact us via email book@nirvanawellbeingretreat.com.au or phone (07) 5531 0511 (Shanti Yoga Southport Office, Mo - Fri).

    RETREAT DATES:

    CLIENT INFORMATION

    FIRST NAME:

    LAST NAME:

    CONTACT PHONE:

    EMAIL:

    ADDRESS (street address, suburb, postcode, state):

    DATE OF BIRTH:

    PLACE OF BIRTH:

    TIME OF BIRTH:

    AGE:

    GENDER:

    REFERRED BY:

    OCCUPATION:

    PRESENT HEALTH CONCERNS:

    CURRENT MEDICATIONS (including herbal supplements):

    PREVIOUS HEALTH ISSUES:

    FAMILY HISTORY:
    Mother

    Father

    ALLERGIES:

    NUMBER OF CHILDREN:

    AGES OF CHILDREN:

    YOUR SOCIAL LIFESTYLE / INTERESTS:

    YOUR HEALTH AIMS:

    Please give details of the food and drink that you generally consume in your day. For example, you may have a variety of breakfast meals that you rotate, i.e. Special K, frid eggs, toast and jam etc. Please list all your options in the categories.

    UPON RISING:

    BREAKFAST:

    MORNING TEA:

    LUNCH:

    AFTERNOON TEA:

    PRE-MEAL SNACK OR DRINK:

    DINNER:

    AFTER DINNER SNACK OR DRINK:

    BEFORE RETIRING:

    SPECIAL TREATS:

    ALCOHOL:

    TAKE-AWAY:

    WATER INTAKE:

    COFFEE AND TEA:

    VEGETARIAN/VEGAN/MEAT:

    DISCLAIMER

    DATE:

    PRINT NAME:

    Nirvana Wellbeing Retreat News

    Live well. Get well. Be well. At Nirvana.