AYURVEDA TREATMENT FEEDBACK FORM

NAME:

DATE:

TIME:

Please complete this form with as much detail as possible and submit on a regular basis via email so your progress under treatment can be monitored and adjustments/guidance given where necessary.

Please give full and detailed responses rather than writing  “the same”, or “as before” or “no change” etc.

1.            Bowel Movements:

Frequency –

Form (bulk, loose or broken, hard or soft) –

Do you experience any pains or cramps?

2. Sleep:

How many hours do you sleep and has your sleep improved or worsened?

Do you experience dreams or nightmares?

Do you wake up feeling fresh or tired?

3. Appetite:

Explain how your appetite has changed if at all –

Do you experience hunger or not and at what times of the day?

How many meals/day do you eat?

Do you eat out or cook at home? Is this different to before?

How do you manage your Dietetics?

Do you experience pain or cramps in the abdomen?

4. Mental/Emotional State:

Are you calmer & more composed?

Do you experience any anger & aggressiveness?

Are you accepting & tolerant?

What meditative practices do you follow?

Have you observed any changes to your mental/emotional state since you started your treatment (this includes your Lifestyle and Diet adjustments)?

5. Menstruation:

Are there any changes to your cycle?

Is any PMS experienced worse or better?

6. Urination:

What is the frequency of urination?

What quantity of water is drunk daily?

What is the colour of the urine?

Any pains or cramps experienced?

7. Exercise:

What type of exercise(s) do you do?

What is the frequency and duration of exercise?

8. Herbal Support:

What is the current dosage of herbal support/sovereign jelly (medicines) that you are taking?

Do you have sufficient supplies of recommended herbal support/sovereign jelly (medicine)?

9. Comments or Questions:

Please add additional comments and feel free to ask questions or request clarification where necessary