Dhanvantari Ayurveda Center  Michael Dick, Ayurvedic Practitioner, Leesburg,

Dhanvantari Ayurveda Center

FOLLOW-UP QUESTIONNAIRE 

Name ________________________________________________________________ Date _______________

1.      How long since your last consultation? __________

2.      Were you able to make changes in your diet?  Yes _____   No _____

3.      Did you avoid foods we recommended against?   None _____  Some _____  Mostly _____  Totally _____

4.      Did you feel any changes as regards to the dietary changes you made?  Yes _____  No _____ 

    Can you give some examples if “yes.”___________________________________________________________________

5.      Did you use herbal supplements?  Yes _____  No _____

6.      Were you able to take the herbs regularly?  Yes _____  No _____  Sometimes _____

7.      Did you take the herbs in the amount suggested?  Yes _____  No _____

8.      Did you have any adverse response to the herbs?  Yes _____  No _____

9.      Did you notice any positive changes attributed to the herbs?  Yes _____  No _____ 

    If “yes” what change did you notice ?_________________________________________________________________________

10.  Did you implement any lifestyle suggestions?  Yes _____  No _____

11.  Did you notice any changes from these lifestyle changes made?  Yes _____  No _____ 

    If “yes” what change did you notice? __________________________________________________________________

12.  Since you last consultation please indicate with (B = better   S = Same  W = Worse) changes you noticed in:                                                           

    Sleep _____    Bowel Function _____    Digestion _____     Appetite _____     Energy______     Other ______________________

13.  Are you feeling some greater sense of balance in your life?  Yes _____  No _____

14.  Regarding handouts you received at the prior consultation:   Did you read them?  Y    N        Were they clear?  Y    N            Were they helpful?   Y    N

15.  What is your goal for this consultation? _____________________________________________________

16.   Other comments? ______________________________________________________________________

© Copyright 1998 Michael S. Dick All Rights Reserved rev. 5/99

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