Follow Up Patient Intake KARRI JINKINS, AYURVEDIC HEALTH COUNSELOR, YOGA TEACHER 9172157710 * www.karrijinkins.com Follow Up Patient Intake What herbs are you currently taking? What supplements are you currently taking? Have the lifestyle suggestions improved any symptoms? Have the diet suggestions improved any symptoms? Have the herbal suggestions been tolerated and or improved any symptoms? What is your chief complaint currently? On a scale of 1-10, what is your current feeling about the plan we’ve put together for you? Digestion 112345678910 Appetite 112345678910 Sleep 112345678910 Bowel Movements 112345678910 LMP 112345678910 Tongue 112345678910 Prakriti 112345678910 Vrakriti 112345678910 Name: Date: Email:
