Two Week Ayurvedic Mind Body Cleanse & Educational Program

Name

First Name

Last Name

Address

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Address 2

City

State/Province

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Email Address

Main Phone

Please list the best number at which you can be contacted.

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Date of Birth

Please explain briefly why you have decided to participate in this program.

Is there a main health concern you are wishing to address?

How often do you have a bowel movement? What is the consistency of the bowel movement? { Dry, Loose, Soft etc } Do you have a tendency toward gas or bloating?

Please describe your digestive system.

What is your average bedtime? Do you have any trouble falling or staying asleep?

Please describe your sleeping patterns.

Is there a coating on your tongue? Is there a color to it?

How would you best describe your emotional state?

Which do you have a greater tendency towards?

Have you ever completed any type of cleansing? If so, describe your experience.

Are you at your ideal weight? Would you like to gain or lose weight?

A castor oil flush on Night 6 of the cleanse is followed by a day of rest. Will you be home for this period and are you able to keep Day 7 unscheduled?

Please consult your calendar and plan accordingly.

WOMEN :: Please describe your menstrual cycle and list your next predicted start date. If postmenopausal, please describe any related symptoms.

The castor oil flush night on Day 6 is contraindicated with days 1-3 of menstruation. If necessary, your cleanse schedule may be adjusted.

Are you currently taking any Ayurvedic herbs or Shaktiveda herbal formulas?

Have you had any surgeries? Please name.

Do you take any prescription medications?

Have you ever been or are you currently in care of a psychiatrist or any other psychotherapeutic program?

If yes, when? What type of program?

How would you describe your present state of health?

Your participation in the Two Week Ayurvedic Mind Body Cleanse & Educational Program does not establish a physician-patient or psychotherapist-patient relationship with Gianna Piccardo Ripa nor Dr. Mary Jo Cravatta. This program is for educational purposes and neither Spirit Healing Arts nor Shaktiveda Ayurveda claim that this program will prevent, treat, or diagnose any disease or illness. You should always consult your physician prior to starting any health program or following the recommendations provided through this program. Currently in the US, Ayurvedic Practitioners are not licensed. The recommendations given by Gianna Piccardo Ripa are based upon Ayurveda and consist of simple diet, lifestyle and natural herbal suggestions. They are not meant to replace the instructions from your licensed health care practitioner.

I am not currently under the care of a licensed Health Care Practitioner and have no chronic illnesses.

I am currently under the care of a licensed Health Care Practitioner and being treated for the following conditions / (use space below to explain). I agree not to discontinue any recommendation from my Health Care Practitioner without first consulting with them.

If under care of licensed health practitioner, explain.

Please sign and date your name:

Acknowledge the above medical disclaimer statements and consent your agreement by signing and dating below.