Shaktiveda
Ayurveda with Dr. Cravatta

                                                
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About Dr. Cravatta

 Introduction to Ayurveda

Personal Consultations

Classes

Dr. Mary Jo’s Schedule

Herbal Products

 Internship for practitioners

Awaken Within Workshop

Shaktiveda
Ayurveda with Dr. Cravatta

                                                
 Home Page    
 
Contact  
  
About Dr. Cravatta

 Introduction to Ayurveda

Personal Consultations

Classes

Dr. Mary Jo’s Schedule

Herbal Products

 Internship for practitioners

Awaken Within Workshop



Ayurvedic Consultation Re-Exam Form


NOTE: Please use the Initial Exam Form if it is your first time consulting with Dr. Caravatta.

All fields required, except those marked by an *
Name (First, Last) Email address
Address City
State or Province Zip or Postal Code
Country*
(if changed)		 Occupation*
(if changed)
Home Phone No.
(w/ area code)		 Work Phone No.*
(w/ area code)
Date of Birth
(mm/dd/yyyy)		 Marital Status*
(if changed)
What Ayurvedic practices have you been able to incorporate into your lifestyle?
Do you have any questions about any of these practices?
What is your main health concern?
Please describe your digestive system.
Do you feel comfortable after eating? How often do you have a bowel movement? What is the consistency of your bowel movements? Have these changed from your past habits?
What time do you go to bed? How long does it take to fall asleep? Do you stay asleep?
What area of concern would you like to focus on in this visit?
Please describe your current emotional state.
Additional comments*
(optional)
For Women Only*:
Please describe your menstrual cycle. (Is it regular, do you experience cramps, PMS, etc?)
Indicate the date of your last menstrual period.
Have you ever been pregnant?
How many times?
How many children do you have? If so, what are their ages?
What type of birth control do you currently use or have you used in the past?
Please read this disclaimer before submitting your form:

By clicking the "Submit Form" button below, I am indicating that I understand that this Ayurvedic consultation is to help me gain a greater sense of happiness and personal well-being and is not intended to diagnose or treat disease. If I have a persistent problem it is my responsibility to seek appropriate medical care.

Dr. Mary Jo Cravatta’s Ayurvedic Center


NOTE: Have you forgotten anything? Please double check your form before clicking submit.